Clinical resources

Focus areas in our disease management programs

There are seven focus areas in our disease management programs, which are all free of cost to our members: 

• Asthma
• Depression
• Diabetes
• Cardiovascular (hypertension, hypercholesterolemia/hyperlipidemia, CHF)
• Tobacco cessation
• Extreme obesity with co-morbidities
• Pregnancy/high-risk pregnancy

Contact Priority Health to learn more about what programs may be available to your patients.

Priority Health plan members are automatically enrolled in disease management programs based on claims data, but you may also refer a newly diagnosed patient for enrollment or specific services by calling 800.998.1037. You'll need the patient's:

• Name
• Contract number
• Phone number
• Specific care needs

Or you can:

• Use the online Patient Profile tool to identify patients who need clinical services.
• Schedule a care manager office visit if you would like more information.

Priority Health has a schedule of initial and follow-up mailings and phone calls from our registered nurses. Disease management programs provide patients with:

• Information about their conditions
• Assessment of their immediate needs
• On-the-spot health information including education on risk factors, healthy lifestyles and adherence to evidence-based treatment
• Follow-up, education on or compliance with treatments you have ordered
• Notification of needed tests, abnormal lab values or significant changes
• Reminders for missed services
• Direction to online patient education and interactive modules that support patient decisions and management

To help you manage your patients, we:

• Identify patients for you that require clinical support
• Communicate with you on the care and education we offered the patient
• Notify you of any needed tests, abnormal lab values or significant changes
• Work directly with your practice to maintain a high quality of care

Our CM team includes Registered Nurses (RNs), Social Workers (MSWs), Care Coordinators and Community Health Workers. Care managers conduct individual assessments that consider the member’s physical status, medical history, psychosocial status, social determinants of health and available resources. They then develop care plans with goals and timeframes that the care manager, member and member’s care team can implement and work together to achieve.

Care managers help members address barriers related to:

• Knowledge deficits
• Health literacy
• Financial constraints (i.e., getting medication, food, basic needs)
• Limited mobility impacting the ability to perform ADLs/chores
• Transportation
• Lack of resources
• Lack of caregiver support or other caregiver issues
• Frequent falls
• Frailty concerns
• High-cost care
• Advance care planning
• End of life care

Care management engagement

Members are managed at differing levels of intensity according to program guidelines that have been developed in accordance with regulatory requirements and best practice guidelines.

To refer a member for CM support, gather the following information and complete the referral form:

• Member's name
• Date of birth
• Phone number
• Member ID number
• Provider's point of contact or care manager and their preferred method of communication (secure email, phone)
• Reason for the referral
• Specific medical concerns
• Any other pertinent information discussed during the call that would be helpful to the case manager

Our customer service team can help members who:

• Have questions about their benefits/coverage
• Need to find a PCP, specialist or other provider
• Need to change an address, phone number or PCP information
• Have questions about DME/coverage
• Have questions about a claim or why a bill hasn’t been paid
• Have questions about a prior authorization

Contact member customer service

Our pharmacy team can help members who have questions about medication coverage or cost.

Contact the pharmacy team

To ensure continuity and coordination of care for members requiring outpatient and/or inpatient care and who have coexisting medical and behavioral health disorders, members may receive integrated care management services from our Care Management and Behavioral Health departments. RN and LMSW services include:

• Development of an integrated care plan for members
• Behavioral health follow up for members who screen positive to the PHQ4 tool (depression) during care management assessment
• Follow up for members receiving specialty pharmacy services who present with behavioral health risk factors
• Care manager interface with our Medical Director for consultation and treatment planning
• Care transitions outreach via an outpatient visit in the home and/or telephonic CM protocol

The following member benefits and supports are available based on plan type:

• Home and community-based programs and palliative care
• Transportation
• Meal assistance
• In-home safety assessment and medication reconciliation
• Supplemental benefits such as Silver Sneakers and over-the-counter benefits
• Education and support for chronic conditions
• Remote monitoring services
• Community resources and referrals
• Mental health support
• Advance directive support, including advance care planning workshops
• Travel benefits