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Chronic Care/Disease Management

Health Net Federal Services, LLC (HNFS) provides a chronic care/disease management (CC/DM) education program to TRICARE Select and Prime beneficiaries in the TRICARE West Region. Beneficiaries are identified through claims and billing data as well as through direct referrals for enrollment into one or more education-based management programs targeting the following specific conditions: anxiety disorders, asthma, chronic obstructive pulmonary disease (COPD), depression, diabetes, and heart disease, including coronary artery disease and heart failure.

Educational materials on the specific conditions are mailed to the beneficiary, followed by telephone conversations with licensed professional staff. Beneficiaries who engage in this telephonic program establish individualized education plans and goals based on their clinical circumstances and readiness for change.

The education-based program promotes effective collaboration between beneficiaries, their treating providers and the DM staff toward the goal of improving quality of care and outcomes for beneficiaries with these target conditions.

The CC/DM education program is based on scientific evidence and includes input from clinical content experts in each specialty area. The program’s structure ensures education is provided by qualified health care professionals who use written criteria based on nationally accepted clinical evidence without undue influence of HNFS management or concerns for the plan’s fiscal performance. 

The program also utilizes the annually updated MCG Health Chronic Care Guidelines® as the basis to establish the CC/DM program’s clinical objectives, beneficiary interventions, education approaches and outcomes. When evidence-based guidelines are not available in MCG, the program utilizes the most current version of nationally recognized disease-specific clinical practice guidelines (CPGs) for program development and identification of education module criteria. 

Additionally, the HNFS CC/DM Education Program adopts nationally recognized CPGs as recommendations to doctors and other health care providers for intervention and management of specific medical conditions; however, the recommended CPGs are not a substitute for an individual provider’s judgment.

The CPGs referenced for the CC/DM education program are accessible from the websites of the National Guideline Clearinghouse (NGC) and the Department of Defense (DoD)/Department of Veterans Affairs (VA).
 

How do I refer someone for chronic care/disease management?

If you know someone who would benefit from chronic care/disease management, please make a referral by:

 

Program resources

The CC/DM program also provides information on rights and responsibilities for providers whose patients are participating in this program.

If you are looking for opportunities to receive continuing medical education (CME) credits, we have compiled a listing of organizations for you.