HealthSmart Care Management incorporates a two-part process to positively affect outcomes of high-risk populations: Identify and Manage.

Identify High-Risk Members With MEDai

The use of predictive models through the analysis of members’ monthly claims data and prescription data identifies tomorrow's high-risk members. HealthSmart utilizes the healthcare industry's most sophisticated forecasting technology in the field of predictive analytics and clinical outcomes analysis. MEDai products provide HealthSmart with the following:

  • identification and stratification of high-risk/high-cost members
  • accurate forecasting of future health plan costs
  • identification of cost drivers for high-risk populations
  • evaluation of patient patterns over time
  • actuarial and underwriting support
  • evidence-based medicine guideline compliance monitoring

Once a member is identified for the program, the process begins to identify the member as a mild, moderate or severe clinical status. Stratification of participants is a dynamic process drawing on clinical, utilization and behavioral parameters driven by the availability and frequency of claims data. A participant can be stratified into a different level based on a change in acuity. The MEDai Risk Navigator identifies those members who are at highest risk for future healthcare cost, and allows the users to profile these members by disease, employer group, drug group, etc.

Manage High-Risk Members With Disease Management

Once at-risk populations have been identified with MEDai, our Disease Management services provide innovative, proactive methods of managing and supporting members with chronic medical conditions. Patient education and support are the cornerstones of this program, with improved health being our focus. By using principles of behavior modification and healthcare education, the program enables members to obtain and maintain optimal health by incorporating effective self-management skills and health-conscious behaviors into their daily lives. Treating physicians receive specific patient data and information on nationally recognized standards to ensure all members are aligned with an intervention plan designed to improve clinical and financial outcomes. The following methods are designed to improve the long-term health of members and to conserve benefit dollars:

  • encourage and support lifestyle modifications
  • structure goal-oriented patient and family education related to disease process and complications
  • provide disease-specific brochures
  • regular contact with our Registered Nurses
  • provide monthly reports
  • provide care coordination
  • access to alternative and community resources
  • individualized care plans
  • compliance with treatment plan
  • creation of individualized goals
  • promotion of self management and problem solving skills
  • methods of stress reduction
  • focus on quality of life