Health Management Program

The Health Management Program (HMP) was created to support members who have or are at risk of developing a chronic disease. Our goal is to help members improve their health through education, resources and personalized support.

Telligen was chosen by the Oklahoma Health Care Authority to provide services to HMP members.

The SoonerCare HMP addresses the complex needs of aged, blind and disabled (ABD) members or tribal members not affiliated with a managed care entity. Eligible members have complex health needs with chronic conditions or are at high risk of developing chronic conditions. The comprehensive approach integrates:

• Personalized health coaching
• Behavioral health screenings
• Provider quality improvement initiatives
• Hospital transition management
• Pharmacy review
• Resource management

In the HMP, health coaching is a key component that provides personalized support and guidance to help members achieve their health and wellness goals. Here are the main aspects of health coaching in the program:

Key Features:

1. One-on-One Support
   • Dedicated health coaches work directly with members
   • Regular check-ins and review of progress
   • Personalized attention to individual health needs
2. Services Provided
   • Health risk assessments
   • Goal setting and action planning
   • Lifestyle modification guidance
   • Chronic disease management support
   • Nutrition counseling
   • Exercise recommendations
   • Stress management techniques
3. Benefits
   • Improved health outcomes
   • Better management of chronic conditions
   • Reduced health care costs
   • Enhanced quality of life
   • Increased health literacy
   • Sustainable behavior change
   • Prevention of health complications

The program aims to empower members to take control of their health through education, support and accountability, while working within the Oklahoma health care system's framework and as a member participating in the program.

HMP delivers behavioral health screenings through the assessment process and supports providers in meeting their screening requirements for Medicaid members.

Practice facilitation is a supportive service designed to help health care providers optimize their clinical practices through quality improvement strategies. For Oklahoma providers, practice facilitation typically includes:

Key Components

1. On-site Support
   • Dedicated practice facilitators who work directly with health care teams
   • Regular visits to assess and guide improvement efforts
   • Hands-on assistance with workflow optimization
2. Quality Improvement Focus
   • Help implementing evidence-based practices
   • Support for meeting quality metrics
   • Assistance with population health management
   • Data analysis and reporting improvements
3. Specific Oklahoma Resources
   • Connection to state-specific health care initiatives
   • Alignment with Oklahoma Health Care Authority requirements
   • Integration with Oklahoma's health information exchange systems
   • Compliance with state-specific regulations

Members require transitional care and further follow-up post-discharge to manage ongoing health conditions, as well as assistance understanding and managing high-acuity health conditions, such as hypertension, diabetes, COPD, CAD, obesity, smoking cessation, asthma and behavioral health.

Members receive help in navigating the health care system such as connecting them with contracted PCPs, scheduling appointments with providers, use of motivational interviewing to coach members on appropriate use of ED visits, educating members on acute and chronic health conditions, reviewing medications and discharge instructions, addressing DME needs, and ensuring access to transportation.

HMP transitions of care can be described as follows:

1. Care Coordination Process
   • Identification of members requiring transition services
   • Assignment of care managers/coordinators
   • Development of individualized transition plans
   • Coordination between providers and facilities
2. Key Transition Points
   • Hospital to home
   • Primary care provider changes
   • Specialty care coordination
3. Support Services
   • Medication management and reconciliation
   • Follow-up appointment scheduling
   • Transportation assistance
   • Resource coordination for equipment and supplies

In the HMP, members receive a medication reconciliation, which is a comprehensive process of reviewing and comparing medication information with the member to ensure accurate and safe medication management. The health coach will discuss medications and provide a med reconciliation at each encounter. The key aspects of medication review:

• Regular review of prescription medications
• Identification of potential drug interactions
• Monitoring for medication adherence
• Assessment of medication appropriateness
• Education to members on the appropriate use and side effects
• Create an accurate, up-to-date medication list
• Communicating with PCP
• Referrals and collaboration with pharmacists
• Monitoring for effectiveness

The goal of resource management is to address SDOH that are barriers to members in accomplishing their health goals. Resource referrals serve as a crucial cornerstone of member support. The program functions as a bridge, connecting members to essential health care and community services through a comprehensive referral system. This integrated approach ensures that members can access things such as:

• Primary care providers
• Specialists
• Mental health professionals
• Preventive care services
• Community resources
• Social services
• Transportation assistance
• Food security programs
• Housing support

If you have been selected to participate in the HMP, you will get a letter in the mail and a phone call telling you that you’re in the program. The program is free. You will never be asked to pay for any of the services the health coach provides.

If your doctor has told you that you have a chronic condition such as diabetes, asthma, high blood pressure or heart disease, and you would like help managing your health, please call 877-252-6002 to be connected with care management.