The Disease Management program provides case management and education for persons living with serious mental illnesses and physical health concerns (i.e., comorbid). Highly trained nurses manage patients' persistent medical issues, such as, diabetes, asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular conditions.
Based on a review of pharmacy and medical claims data, a quarterly Disease Management Report flags patients with selected health conditions for whom appropriate screening and treatment activities appear to be lacking. The report allows nurses to quickly identify patients for whom intervention is necessary and to assure that their medical needs are addressed, thereby increasing patient physical wellbeing and reducing the costs associated with treating poorly managed conditions.
Aggregated data provides agencies with snapshots of the proportion of their population receiving recommended screenings and treatment for each of a series of indicators, thereby allowing agencies to target resources to critical areas and to set goals and monitor progress as part of quality assurance operations.
Disease Management is available in Bollinger, Cape Girardeau, Madison, Perry and Ste. Genevieve Counties
Funding: Department of Mental Health and MO HealthNet