Module 1 lesson 6 adrm and cnbr (mco)

Module 1 lesson 6 adrm and cnbr (mco)

• 1.
  Working towards ahealthier you Managed Health Risk Solution Lesson 6
• 2.
  Working towards ahealthier you Part A Active Disease Risk Management (ADRM)
• 3.
  Who we are ADRMis a program focusing on high risk members with high risk identified through a predictive model Medscheme has an advanced predictive model which identifies and risk stratify high risk beneficiaries. These high risk beneficiaries have various co-morbidities and they have an increased chance of being hospitalised within 12 months. Knowing who these beneficiaries are allow us to tailor our interventions for these beneficiaries ensuring that the Scheme risks are efficiently managed. 3
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  What we do ADRMintervenes on these beneficiaries High risk beneficiaries identified bi-annually through predictive modelling and. Once loaded on system, a welcome letter will be sent to these beneficiaries. Our interventions are primarily on 3 levels – ADRM Level 1 (Non Clinical), ADRM Level 2 (Clinical) and Life coaches. The conversations are in the format of a questionnaire where all information exchanged is recorded. 4
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  Why we dowhat we do The intention is to gain insight into the beneficiary’s treatment adherence, outcome of tests done, assistance required by the beneficiary, identifying high risk factors and relevant referral to the FP if required. In addition to the FP referral, risk factors from Level 1 will also trigger to Level 2 where a Clinical Care manager will intervene on the following programs:  Asthma  Cardiovascular disease  Diabetes types 1 & 2  Mental Wellness (Depression and Bipolar) Beneficiaries are followed-up after 3 months and if additional support is required more regular follow- ups will be scheduled. Other programs being managed by the team -  High Risk Maternity  Post discharge program 5
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  What we don’tdo We do not confirm member benefits MH does We do not grant any authorisations. Hospital authorisation does We do not do face to face sessions or home visits 6
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  Which SPN wecollaborate with Healthi Choices. Healthi Choices provides MHRS with data of high-risk maternity members and wellness days outcomes for ADRM to intervene on. ADRM calls members and provides Health information and interventions 7
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  Frequently asked questions Whatqualifies as a High-Risk member? We have a Heath Intelligence unit that uses a predicative model to identify members. 8
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  Escalation [email protected] is theemail address queries can be referred to 9
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  Identified knowledge andservice delivery gaps Fragmented service delivery can impact turn around times but platforms like these help in closing those gaps 10
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  Working towards ahealthier you Part B Chronic Back & Neck Rehabilitation Programme (CBNR)
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  Who we are 12 DBC/Workabilityis a multidisciplinary primary care spinal rehabilitation programme. The purpose of the programme is to rehabilitate back and neck through appropriate primary and preventative care treatment. This will reduce the need for back and neck related hospital admissions
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  What we do The focus is on primary care. The family practitioner is the coordinator of the spinal care and it is complimented by the rest of the multidisciplinary team (including a physiotherapist and biokineticist). Members identified or referred for the programme will be contacted and receive related information. Members will be referred to the nearest DC or Workability centre and appointments will be managed by the centre The centre will perform an assessment which will determine the treatment. Treatment will need to be completed in order for the member to benefit the programme. 13
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  Why we dowhat we do To rehabilitate and/or prevent surgery A baseline assessment is undertaken by the DBC/Workability centre for suitability. Assessment will determine if member will require low, medium or high-risk treatment. Patients exercise twice a week as this is the optimal physiological function required by spinal muscles. Maintenance – Members are allowed 2 repeats (1 on a quarterly bases) to monitor the progress of the patient. 14
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  What we don’tdo We do not deal with claims. Metropolitan Health is the custodian of claims We do not deal with appliances We do not do clinical assessments. Assessments are done by the respective Rehabilitation centre 15
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  Which SPN wecollaborate with Metropolitan health whom process claims 16
• 17.
  FAQs – thetop four Can the CBNR program be used for individual Physiotherapy session? No it can not as a programme that comprises of multiple sessions that needs to be completed When will the CBNR program be available everywhere in the country? The DBC and Worablity networks are working hard to expand their reach in areas that are not currently covered. In the last year the amount of centres in the Eastern Cape has doubled for example. Is the CBNR program an unlimited benefit? No it is not. The programme will have a set amount of sessions based on members need and Risk assessment. Can I attend the program as many times as I want? Each member is allowed one Authorisation per benefit year 17
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  Identified knowledge andservice delivery gaps Service only provided to members identified within 30 kl radius from Centre Centres not available in all provinces or areas as yet 18
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  Contact details forreferrals 19 There are a number of ways to access the programme: Telephone: 0860 00 43 67 Email: [email protected] Your Scheme may contact you if you had back problems in the past and had related treatment Your GP or Specialist may refer you to the programme
• 20.
  ADRM and CBNRcontact details We are outbound and only communicate our contact details to identified High Risk members The contact number provided is to contact us for Health advise 20
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  Assessment questions How manylevels of intervention are there in ADRM? Our interventions are primarily on 3 levels – ADRM Level 1 (Non Clinical), ADRM Level 2 (Clinical) and Life coaches What programme do Clinical Care Mangers intervene on?  Asthma  Cardiovascular disease  Diabetes types 1 & 2  Mental Wellness (Depression and Bipolar) Beneficiaries are followed-up after 3 months and if additional support is required more regular follow-ups will be scheduled. 21
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  Assessment questions continued Whatis the purpose of the CBNR programme? The purpose of the program is to rehabilitate back and neck through appropriate primary and preventative care treatment How is risk determined by CBNR programme? Assessment will determine if member will require low, medium or high risk treatment. 22
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  Escalation process All ADRMand CBNR escalations should be sent to [email protected] All claim related queries are to be sent to MH Only health related queries to be sent for ADRM Only queries related to registration and information on the CBNR should be sent 23
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