Condition Control - General Information – Test Zendesk Vida

Program Description

The Condition Control program manages co-occurring condition(s), with a focus on congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and hypertension (HTN).

Program Highlights

A revamped version of our CHF/COPD programs
Focus on building healthy habits to manage CHF and/or COPD, in addition to any co-occurring conditions. Coaches will focus on:
- Medical history and medication intake
- Providing support and reinforcement of program and prescriber plan: focus on early identification of symptom changes/exacerbations in an effort to avoid unnecessary hospitalizations (escalate care as needed)
- Address members personalized goals/behavior change in the areas of eating, fluid intake, sodium intake, exercise, sleep, and stress
- Identifying gaps in care, including prescribing or deprescribing needs
- Continue to support members key tracking of symptom burden, weight, food, etc as needed
- As needed -Integrate support for additional mental health, including escalation when appropriate
5 Remote Patient Monitoring Protocols / Rescue Outreach Interventions:
- Critical BP scores, critical Heart rate, sudden weight gain or loss, spike in symptoms reported, blood oxygen
- Used to alert the member when action is needed via text, app notifications and some coach phone outreach depending on severity
- Some actions could be the direction to go to the ER if medically necessary
- Some On-call prescribing functionality

PROGRAM MANUAL VP CARD.

Member Experience

Based on the conditions found during onboarding, members will have default trackers available to manage symptoms, track medication adherence, and monitor metrics like weight, blood pressure, SpO2 or heart rate. They might also qualify for devices like scales, blood pressure cuffs, or pulse oximeters to improve tracking. If any metrics show as abnormal or critical, members will experience our rescue interventions. These interventions involve automated alerts and/or responses from our care team to address the situation, and notifications will be via email, text, and outreach calls from coaches/prescribers in some cases. If a member receives one of these alerts, they will often be provided the below “On-call prescriber” number so they can leave a message with a prescriber who will call them back quickly to discuss the issue. Members can expect a response within 24 hours if it’s critical, within 72 hours for out-of-range scenarios. You can also direct members to this number if they have questions or concerns about the alert/notification. Encourage them to also follow any instructions in the alert/notification that was sent.

On-call Prescriber Support

On-call Prescriber Voicemail Line: 1 (888) 703-8034

This line is set up in Zendesk for members to call for critical scenarios such as acute fluctuations in readings (BP, heart rate, weight), sudden changes in symptoms or side effects, alerts to go to the ER, etc. Members will leave a VM, and an on-call prescriber will receive a notification via email and slack that prompts them to take action.

If you receive an inbound call or email regarding such scenarios, please respond with the following:

If you need to seek medical attention right away, please call 911 or your local emergency services. Otherwise, your concern is best handled by our on-call prescribing team. You will need to call (888) 703-8034 and when prompted, leave a message. One of our on-call prescribers will get back to you as soon as possible.

Launch Details

Date: 1/1/2024

Types of providers for this program

Health Coach - Introduces the program, captures goals and continuously tracks progress and symptom changes.

Registered Dietitian - If a member is unintentionally losing weight, an RD will be referred to assess medical hx, labs, meds, weight history, food logs. From there they identify the nutrition diagnosis and formulate a nutrition plan that includes education, nutrition prescription and oral nutrition supplements.

Prescriber - Captures and reviews member’s medical history, assess for inhaler technique if member has COPD, prescribe labs or rescue meds, discuss self-monitoring practices and coordinate plan for symptom changes/exacerbations in an effort to avoid unnecessary hospitalizations, looks for gaps in care and any prescribing/deprescribing needs. Prescriber is added shortly after program enrollment to complete evaluation.

Eligibility / Inclusion Criteria

Members will be recommended for Condition Control if they have CHF or COPD, even if they also have co-occurring diabetes or hypertension.
If a member is from Highmark, they will automatically get placed in Condition Control
- This is the only program launching for this org on 1/1/24. If the member is deemed ineligible due to exclusion criteria during their meeting with their coach, they will be offboarded.

Exclusion Criteria

<18 years
Pregnant
Chronic Kidney Disease Stage V w/ or w/o dialysis
Cytotoxic chemotherapy/radiation in last 6m
End Stage Liver Disease
Organ or bone marrow transplant in past 1 yr
Palliative/hospice/end of life care
- offer Resilience
Current mental health exclusions: criteria for suspending, deactivating (via CN/Therapist assessment)

Program Goal

Reduce inpatient or ER admissions.
Improve self-management skills
Improve quality of life

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Condition Control - General Information