Health Management Program FAQs

The Oklahoma Health Care Authority (OHCA) has contracted with Telligen, the largest quality improvement organization in the United States, to operate the Health Management Program (HMP). Telligen brings extensive experience in managing similar programs across the country, along with a strong foundation in financial stability and proven success in quality improvement initiatives. Their partnership ensures that Oklahoma’s HMP delivers meaningful support to SoonerCare members and their primary care providers.

SoonerCare Choice members who:

•  Have or are at risk for developing chronic disease(s).
•  Are at high risk for adverse outcomes.
•  Have an increased likelihood of experiencing a health care crisis.

• Telephonic or in-person health coaching by a registered nurse at participating providers’ offices.
• Educational materials and support regarding their health condition.
• Behavioral health screening and access to behavioral health resources.
• Help with locating community resources.

Primary care providers participating in the Health Management Program receive a range of valuable services designed to enhance patient outcomes and support clinical excellence.

Participating PCPs have the opportunity to take part in structured quality improvement (QI) initiatives aimed at strengthening chronic disease management and preventive care. These initiatives include:

• Continuing Medical Education (CME) Credits
  Providers can earn CME credits through their involvement in QI activities.
• Evidence-Based Educational Resources
  Access to clinical tools and materials rooted in the latest evidence-based guidelines.
• Practice Facilitation Support
  Assistance from dedicated practice facilitators who help implement and sustain effective clinical workflows, team-based care strategies and data-informed decision-making.

These services are designed to reduce the burden on providers while promoting better outcomes for SoonerCare Choice members with or at risk for chronic conditions.

• Program Introduction
  Participating providers will first receive an introductory letter with key information about HMP and what to expect.
• Embedded Health Coach Support
  Selected providers may be offered the opportunity to have a health coach embedded within their practice. These coaches work directly with SoonerCare Choice members who have chronic health conditions 
  • What is a health coach?
    A health coach is a registered nurse trained in motivational interviewing and chronic disease management. They support patients in setting goals, managing conditions and making sustainable health improvements.

For more information about the role and impact of health coaches, please visit our Health Coaching page.

Practice facilitation is a support service and quality improvement strategy designed to help health care practices, particularly primary care practices, implement evidence-based approaches and make meaningful changes to improve patient care and outcomes.

Practice facilitation provides primary care providers with various supportive services designed to help them improve their practice operations, quality of care and patient outcomes. Types of services typically offered through practice facilitation:

• Quality Improvement Support
  • Data collection and analysis assistance.
  • Performance measurement guidance.
  • Implementation of evidence-based practices.
  • Development of quality improvement strategies.
  • Workflow optimization.
  • Performance Monitoring 
    • Metrics tracking.
    • Benchmark analysis.
    • Progress reporting.
    • Outcome measurement.

Practice facilitation helps primary care practices enhance their operations through dedicated professionals who guide them in implementing positive changes to improve patient care outcomes. These trained specialists, known as practice facilitators, work directly with health care practices to develop and sustain quality improvement initiatives.

The duration of practice facilitator engagement in primary care settings varies significantly based on the scope of services, practice needs and specific improvement goals. While the typical engagement ranges from 3-6 months, some practices may require more intensive support extending up to 12-18 months.

The level of involvement can range from focused, short-term interventions like academic detailing sessions lasting several weeks, to comprehensive practice transformation initiatives requiring long-term facilitation.

Factors influencing the timeline include the practice's size, current workflow efficiency, staff readiness for change, and the complexity of targeted improvements. Most successful implementations follow a graduated approach, beginning with more intensive on-site presence that gradually transitions to remote support and periodic check-ins as the practice develops sustainable improvement capabilities. Regular assessment of progress and flexibility in adjusting the facilitation timeline ensures optimal outcomes for the practice.

OHCA HMP practice facilitation functions, grouped into key strategic areas:

Assessment & Analysis

• Conduct comprehensive practice assessments and workflow evaluations.
• Perform data analysis through claims and chart review.
• Identify care gaps and quality improvement opportunities.
• Evaluate current office processes and efficiency metrics.

Strategic Planning & Goal Setting

• Partner with providers and key stakeholders to develop actionable goals.
• Create customized improvement action plans.
• Establish measurable outcomes and benchmarks.
• Design system optimization strategies.

Implementation & Process Improvement

• Guide practice transformation initiatives.
• Implement evidence-based workflow redesigns.
• Develop team-based care models.
• Establish quality improvement protocols.

Education & Capacity Building

• Provide staff training on quality improvement methodologies.
• Foster collaborative team-based approaches.
• Build internal capacity for continuous improvement.
• Empower staff with process improvement skills.

Monitoring & Sustainability

• Track progress against established goals.
• Monitor implementation of interventions.
• Ensure long-term sustainability of improvements.
• Evaluate outcomes and adjust strategies as needed.