Disease Management
Our leading-edge disease management programs address some of the most costly and deadly chronic conditions. For each disease and for each person, we incorporate evidence-based, nationally accepted clinical protocols along with a personalized plan to deliver a program best suited for that individual. Our Disease Management programs include:
U.S. Care Management associates have applied successful health management strategies for asthma since 1995. Our asthma disease management program is recognized for more than just helping sufferers breathe easier. It's a breath of fresh air for employers and payers, too. The asthma disease management program includes in-home assessments and education, educational materials for both patients and physician, the establishment of treatment guidelines, coordinated care with the patient's physician, pre- and post- patient questionnaires, as well as claims and results-monitoring.
We put our well-known asthma disease management program to the test back in 1995. From a pool of patients who had either two Emergency Room visits or one hospitalization, our voluntary program reduced hospitalizations to zero, decreased ER visits by 75% and doubled the level of asthma trigger awareness.
| Chronic Obstructive Pulmonary Disease (COPD) |
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U.S. Care Management's community based model is essential in managing persons with COPD who need hands on assistance in reducing conditions that aggravate their chronic disease. Education, care coordination, adherence to treatment plans, physician and patient relations, referrals to community based support programs and self-care initiatives all lead to more positive outcomes when the nurse and client work together.
For example, our COPD management clients are often long time smokers, so U.S. Care Management registered nurse care managers provide education on the reasons and techniques for smoking cessation and refer clients to support resources such as the Nicotine Quit Line. Our nurses have also helped to initiate Nicotine Anonymous Support groups in areas where they did not exist. The value of relationships helps open the path to improved health.
When U.S. Care Management's registered nurse care managers visit persons with diabetes at home, they see the opportunities to improve. Our nurses use their clinical, educational and specialized health management training to coordinate care, change nutritional and exercise behaviors, improve self-care and build understanding of how clients can work with their health care providers.
Diabetes disease management and obesity disease management involves changing the way a person perceives their disease, as well as the conditions that contribute to their health. This is where the value of relationships takes over. For example, personalizing the impact of weight loss can have a dramatic affect on people who have diabetes and other chronic conditions. U.S. Care Management's registered care nurse managers have started walking clubs for members, referred them to support groups and taught food preparation techniques to disease management members and caregivers.
Diabetes disease management programs effectiveness is measured through clinical indicators including A1c levels, weight and blood pressure. Examples of U.S. Care Management's success include increasing the incidence of A1c levels being performed by 40% among the population with diabetes for an employer group and significantly reducing the average A1c by 1.03% among a schizophrenia population with diabetes. Based on a 2001 article in the Journal of the American Medical Association by E.H. Wagner, improving (decreasing) the A1c by 1% will result in an average healthcare savings of approximately $685 per year.
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U.S. Care Management follows evidence-based national practice guidelines for diabetes established by the American Diabetes Association (ADA) and has worked with high risk persons with diabetes since 2000.
1 Wagner, E.H.; Sandhu, N.; Newton, K.M., McCulloch, D.K.; Ramsey, S.D.; Grothaus, L.C.; Effect of Improved Glycemic Control on Health Care Costs and Utilization”, JAMA, 2001.
U.S. Care Management's unique community-based approach engages community resources and providers, and the USCM staff has successfully overseen the management of HIV clients. Our program focuses on the critical issues required for success, including appropriate antiretroviral therapy, adherence and the management of co-morbidities which are becoming a greater factor as persons with HIV/AIDS live longer and experience the other illnesses associated with aging.
U.S. Care Management has designed a Hepatitis-C management program . Hepatitis-C is a blood-borne viral disease spread by blood-to-blood contact which may cause liver inflammation, fibrosis, cirrhosis and liver cancer. The Hepatitis-C management model for care of HEP-C patients focuses on providing best practice, education on self-management and adherence, and the monitoring of care utilization.
evidence-based national practice guidelines for HIV from the Centers for Disease Control and Prevention (CDC) and the Department of Health and Human Services (DHHS). U.S. Care Management first implemented an HIV health management program in 1997.
U.S. Care Management's community based health management model offers a vital service to people with hypertension, coronary artery disease and heart failure. The hypertension management program binds the resources needed to maximize the care and self-care needed to effectively manage cardiovascular conditions. Our primary nursing care model with in-home assessments, education, care coordination, adherence to the physician's treatment plan and ongoing monitoring of clinical outcomes enables the hypertension management program to be successful where a less personal touch is not.
We have experienced average reductions in LDL within a coronary artery disease population by 11.9%.
U.S. Care Management follows evidence-based national practice guidelines for hypertension, coronary artery disease and heart failure established by the American College of Cardiology (ACC) and the American Heart Association (AHA) and has worked with high risk persons with cardiovascular disease since 2002.
In December 2005, U.S. Care Management implemented a high risk pregnancy DM program awarded by the state of Florida. The Program serves Medicaid eligible (fee-for-service) pregnant women and is designed to reduce preterm deliveries and costs that are linked to unnecessary utilization of services. U.S. Care Management staff members first worked with high risk pregnancy clients in 1996 when they developed and implemented a successful high risk pregnancy health management program for a Medicaid managed care organization.
Schizophrenia, Mental Health and Depression Management
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U.S. Care Management recognizes the impact that behavioral health has on all chronic conditions and has implemented a community based program specifically addressing schizophrenia. The U.S. Care Management registered nurse care manager's relationship with clients is needed to address the many medical, behavioral and social needs of persons with schizophrenia. Diet, sedentary lifestyles, excessive smoking habits, limited personal support and obesity often contribute to co-morbid conditions that affect their well-being. U.S. Care Management's mental health management program has improved clinical outcomes (A1c, weight loss, vaccination rates) and compliance with physician treatment plans.
For example, U.S. Care Management significantly reduced the average A1c by 1.03 among a schizophrenia population with diabetes. Based on a 2001 article in the Journal of the American Medical Association by E.H. Wagner, improving (decreasing) the A1c by 1% will result in an average healthcare savings of approximately $685 per year.
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U.S. Care Management follows evidence-based national practice guidelines from the American Psychiatric Association (APA) and has worked with persons with schizophrenia since 2002.
1 Wagner, E.H.; Sandhu, N.; Newton, K.M., McCulloch, D.K.; Ramsey, S.D.; Grothaus, L.C.; Effect of Improved Glycemic Control on Health Care Costs and Utilization", JAMA, 2001.