Heart and Vascular Disease Case Management Program
Please provide the member’s name, date of birth, current lab results and current progress note.
Physicians Plus is committed to supporting effective provider-member interactions to reduce and prevent heart and vascular disease. This nurse case management service aims to reduce cholesterol, blood pressure, body mass index, cardiac events and other long-term complications at no cost to high-risk members.
Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. (CMSA, 2009).
Who is Eligible?
Physicians Plus members, age 18 or older, having a hospitalization for MI, PTCA, PCI or CABG, or identified by a provider as needing additional resources to reach treatment goals. Self-referrals are also eligible for participation.
How Does it Work?
A Physicians Plus nurse case manager individually assists members in assessing risk factors and making lifestyle changes. The program typically lasts up to six months with telephonic checkups specific to the member’s care plan.
1. Physicians Plus staff identifies members through medical claims and obtains provider support to enroll member.
2. The nurse case manager contacts the member to enroll in the program and complete the care assessment.
3. The nurse case manager notifies the primary care provider whether or not a member volunteers to enroll.
4. The nurse case manager works with the member and provider to develop a care plan including:
- Mutually agreed upon, realistic self-care goals for diet, exercise, weight loss, stress reduction, tobacco cessation and emotional health;
- Self-care tools and education to enable these changes to occur;
- Care coordination with physicians, dieticians, health educators and exercise physiologists;
- Community resources to help the member achieve these goals;
- Glucose, blood pressure and cholesterol monitoring to make timely interventions when needed; and
- Medication review for optimal treatment, coordinated by our pharmacists.
5. Providers are copied on written communications to members regarding self-care goals, program participation and care recommendations.
6. Members are transitioned to monitoring status or graduate when care goals are achieved and sustained.
Member Blood Pressure Management Tools
Cardiovascular Health Management Tools for Providers
- Preventing Cardiovascular Events, Practitioner Tool Guide, developed with the Wisconsin Collaborative for Cardiac Event Reduction Initiative