Studies show that employee participation in health screenings and education throughout the year improves health, morale, and productivity.

Identification - Using several methodologies for identifying specific individuals who might benefit from intervention. Initial triggering may occur through utilization management reviews, the referral process, predictive modeling, customized medical management reporting, the third party administrator, and through other identification mechanisms. 

Screening - Cases of all covered Participants that are triggered.  The Case Manager (CM) will evaluate the individual to ensure the following can be realized: Identification of the best treatment(s) for the condition(s); Assessment of the best setting for the delivery of the treatment; Projection of potential cost savings; and Improvement in patient outcomes. 

Open Cases - Typically based upon a standardized assessment by the CM when a determination is made that health care quality and cost can be positively impacted.  Cases usually are kept open as long as that impact is deemed appropriate and is expected to produce a return on investment (ROI) of a minimum of 2 to 1 and a target of 4 to 1.  Cases are closed when these goals can no longer be met, but can be re-opened at a later time if the expected or target ROI of a Case Management intervention can be re-established.

Intervention - If a particular case qualifies, the CM will contact the Participant to enroll them in the program.  The CM will support the Participant through the activities, for examples: 

Serving as the clinical guide to support the patient along the continuum of care;
Identifying appropriate clinical guidelines or clinical review criteria;
Using predictive modeling tools and clinical research to support the patient;
Working closely with the treating physicians and other treating professionals in part by using the Clinical Claims Chart, Clinical Guidelines, and the patient care plan;
Comparing treatment with evidence-based guidelines or "best practices";
Reviewing databases to educate the Participant and their primary care physician regarding who are the high quality provider specialists/facilities regarding the required health services in the Participant´s region;
Developing a patient care plan;
Coordinating services necessary to improve health status and impact cost of care;
Facilitating appropriate use of resources;
Facilitating referrals to education programs within the local communities when able;
Educating the Participant and enabling achievement of best possible level of wellness;
Promoting interaction to achieve "buy in´ to and compliance with the goals of Program;
Reporting variations in medical practice patterns to the treating provider or the appropriate medical director regarding nationally-accepted Clinical Guidelines or normal reimbursement levels;
Negotiating price when appropriate; and
Documenting and reporting quality and cost outcomes.