Disease Management

Population Health Management / Disease Management

Purpose

Management of chronic diseases in order to improve participant health and reduce insurance costs. Population Health Management seeks to improve the health outcomes of a group by monitoring and identifying individual patients within that group. Based on data collected through screenings, providers can track and hopefully improve clinical outcomes while lowering costs.

Benefits to Participants


  • Receive lifestyle coaching
  • Access to interdisciplinary team
  • In some cases, benefits such as waived co-pays for office visits and medications
  • Measurable health improvement through dedicated care

Benefits to Company


  • Health care cost reduction
  • Improved productivity
  • Improved employee satisfaction
  • Commitment to empathy and innovation
  • Provide premium level of service to members

Care Management Team

  • Clinic Providers
    • Various medical doctors, nurse practitioners and physician assistants
  • Care Liaisons
    • Nurses
  • Registered Dietitian 
    • Credentialed nutrition expert, provides lifestyle coaching
  • Certified Diabetes Educator/Pharmacist
    • Aids in management of medications, insulin regimen, and provides lifestyle coaching
  • Nutrition Coaches
    • Provides additional lifestyle coaching with the support of the RD

Visit Types

  • In-office at clinic location
  • Telephonic
  • On-site coaching 
  • Lunch & learns
  • Health challenges
  • Digital

Lifestyle Coaching

Services are provided for contracted companies, but also on an individual basis at a private cost

Description of Appointments

  • Confidential one-on-one
    • 30 min session
    • Build rapport
    • Discuss lifestyle components 
    • Provide education – verbally, supported by handouts
    • Set goals
    • Provide accountability and support
  • Frequency of Visits
    • Weekly - Monthly
    • Gather data to quantify improvements in health

Life Coaching Process

Program Types

Disease Management


  • RD, CDE/Pharmacist, and nutrition coach
  • Components of wellness program with a focus on chronic conditions: prediabetes, diabetes, hyperlipidemia, hypertension, metabolic syndrome
  • Modifying lifestyle factors to prevent complications
  • Current large and structured programs: Diabetes management

Wellness


  • RD and nutrition coach
  • General nutrition education
  • Weight management
  • Bariatric procedure counseling
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