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Population Health Management Programs

A variety of clinically based programs are in place for addressing the needs of members across the continuum of care. These include multiple health management programs for members with complex health care needs, physical or developmental disabilities, multiple chronic conditions, and severe mental illness.

These programs are designed to meet the care needs of the member population through identification, participation, engagement, and targeted interventions aimed at active engagement in health care services. The goal is to maintain or improve the physical and psychosocial well-being of individuals and address health disparities through cost-effective and tailored health solutions.


The goal of the asthma management program is to:

  • Improve the health status for members using a multidisciplinary, population-based approach
  • Manage health care costs by promoting evidence-based treatment while assisting members to achieve optimal control of their illness

Interventions are individualized and targeted to specific member needs based on the member’s level of self-management.

Attention Deficit Hyperactivity Disorder (ADHD)

The Attention Deficit Hyperactivity Disorder (small attention span) management program aims for proper screening, diagnosis, treatment and management of ADHD in children. We work closely with our pediatric and behavioral health doctors to develop activities and educational materials that encourage parents to get the right help for their children.

Chronic Obstructive Pulmonary Disease (COPD) 

The goal of the COPD program is for members to control their symptoms and maintain an active lifestyle. An individual’s quality of life can be seriously affected if COPD is poorly managed. We provide tools to assist in controlling symptoms and staying healthier longer. Spirometry testing and medication management (corticosteroids and bronchodilator) rates are measured to determine program success.


The primary focus of the depression management program is to improve the quality of life for our members with depression by assisting them in getting the right treatment, medications, and follow-up care. We want to ensure our members receive appropriate office follow-up after an antidepressant medication has been prescribed or following hospitalization.

Diabetes (Sugar in the Blood)

The diabetes program is designed to promote compliance with diabetic care and raise awareness of the effects of poorly controlled diabetes. Appropriate and timely screening and treatment can significantly reduce the long-term complications of diabetes. We continue to educate and encourage members to participate in recommended tests (e.g., blood sugar and cholesterol, eye exams, etc.) to monitor their diabetes.

Cardiac Program

The cardiovascular health program was developed to address growing concerns about cardiac disease. The program addresses members at higher risk for complications associated with cardiovascular diagnosis.

Hip and Knee

This program was developed in July 2017. It is designed to raise awareness and improve outcomes related to the cause, treatment, and management of osteoarthritis of the hip and knee, with both our physicians and members.

Patient self-care education starts as soon as possible after osteoarthritis diagnosis of the hip or knee to prevent life-changing complications. One-on-one health coaching is an integral part of the process. Health professionals are specifically trained to provide coaching over the phone.

As part of this member-centered approach, the health coach actively listens and works collaboratively to achieve desired health goals and enhance the overall quality of life for every member. Identified members are encouraged to participate in preventive visits with providers. Education is focused on conservative treatment options and lifestyle techniques for improved health, including exercise, smoking cessation, and weight loss, as needed.

Spine Program

The program goal is to raise awareness and improve outcomes related to the cause, treatment, and management of back-related conditions with both our providers and members.

Stroke Prevention Program

The stroke prevention program is aimed to reduce the incidence of strokes through primary prevention and improve secondary prevention efforts to further lower risks of stroke-related morbidity. Through this quality-based integrated care model, collaboration, provider and community support, and partnerships are incorporated to promote best practices. This includes:

  • Integrated validated risk-modeling and stratification
  • Focused health coaching
  • Case and disease management outreach
  • Medical protocols
  • Pharmacy management to significantly expand screening for atrial fibrillation (AFib) and broaden the prophylactic use of oral anticoagulants (OACs) in members at risk

Substance-Use Disorder (SUD)

The SUD care management program includes strategies to treat existing dependency among members and prevent future addiction. The comprehensive care management approach includes prevention, treatment, recovery, and specialized services. Substance-use treatment can be characterized as a continuum, dependent on things such as magnitude of the substance-use problem, level of care (inpatient, residential, intermediate, or outpatient), or intensity of services. The continuum ranges from case finding and pretreatment to primary treatment and aftercare.