Care Coordination and Disease Management Services
Care coordination and disease management services can be described as integrated health care. This comprehensive approach helps ensure members receive appropriate, timely and well-coordinated health care services while managing their conditions effectively.
Health Management Program
In response to a state mandate outlined in Oklahoma Statute 56-1011.6, the Health Management Program (HMP) was established in 2008 to enhance the quality of care and reduce health care costs for members with chronic conditions.
Since its inception, HMP has evolved into a comprehensive care coordination model that offers care coordination and chronic disease management support to both members and their primary care providers (PCPs). Health coaches engage with members and their medical homes by phone, while practice facilitators collaborate with selected health care facilities or clinics to optimize care processes for individuals with chronic illnesses.
Comprehensive HMP care management is a coordinated approach to delivering health, mental health and social services that focus on the entire individual. It involves individualized service planning, connecting members to various resources, and tracking their progress to ensure they receive timely and appropriate interventions and quality care delivery. This approach includes assessment, planning, linkage, monitoring and advocacy to address the member’s unique needs and circumstances. For more information, visit the HMP individuals page and the HMP providers page.
Chronic Care Management
Chronic Care Management (CCM) nurses provide telephonic case management to members with chronic health conditions, particularly members who are not aligned with other care management programs and members who can actively participate in self-management. CCM supports members whose complex chronic health conditions can be positively impacted through education and lifestyle behavior change, including a range of chronic conditions including but not limited to asthma, cardiomyopathy, cardiovascular disease, COPD, diabetes, hemophilia, hepatitis C, hypertension, obesity, and sickle cell disease.
Health Access Network
The Oklahoma Health Care Authority has contracted with two Health Access Network (HAN) partners who are affiliated with Patient Centered Medical Home (PCMH) providers to improve the quality of care across Oklahoma. HANs provide complex care management and coordination for members and quality improvement initiatives that support PCMH providers to enhance positive health outcomes for SoonerCare members. Additional information can be found at:
- OSU Health Access Network: health.okstate.edu/health-access-network
- OU Sooner Health Access Network: soonerhan.ouhsc.edu
