Disease Management Programs

CenCal Health strives to enhance the scope of health care services provided by our network of primary care physicians and specialists by implementing Disease Management Programs. These are developed to provide targeted interventions to members with certain high-risk diseases.

How does it work?

CenCal Health identifies members with certain chronic conditions, and develops programs to address their health care needs. These programs work with members, primary care physicians, and specialists to improve clinical outcomes, reduce or delay long-term complications, and improve members' health and well-being. 

Referrals may be made by faxing the Case Management Referral Form to (805) 681-8260 

 

Heart Disease

The heart disease management program helps to improve the treatment and care for people with Congestive Heart Failure and Coronary Artery Disease.

This program works with clients to assess their needs and provide customized health monitoring and education. CenCal Health provides care management and arranges healthcare services with local agencies. Nurses visit the home or conduct a telephone assessment. Together they evaluate individual needs and determine the resources that would benefit the client and caregiver.

Program Goal:

To help improve members’ self-management skills and adherence to treatment plans for their cardiovascular condition(s) as well as to support primary care physicians in the management of their patients’ condition.

Program Objectives:

  • Improve the quality of care in accordance with the AHA clinical practice guidelines for congestive heart failure (CHF) and coronary artery disease (CAD).
  • Improve coordination of care and adherence to treatment programs for members following acute myocardial infarction.
  • Promote a patient-physician interactive approach toward cardiovascular care by using action/goal plans, facilitating patient-physician communication, and encouraging members to take a more active role in managing their condition.
  • Encourage member adherence to physician prescribed treatment plans.
  • Increase member self-management and knowledge of cardiovascular disease, including hypertension and early detection and management of symptoms.
  • Improve compliance to hypertension dietary and pharmaceutical therapies
  • Reduce exacerbation and secondary complications of cardiovascular conditions.

What services can Heart SMART provide?

  • Assistance with medication management
  • Reminders and assistance with follow-up visits to health care providers
  • Education to maintain health and know what to do for worsening symptoms
  • Linkage to resources and health classes
  • Foster patient self-management
  • Telehealth support, including monitoring of weight, blood pressure, and heart rate
  • Provide dietary and lifestyle counseling
  • 24-Hour Nurse Advice Line

Who can receive Heart SMART services?

To be eligible for Heart SMART, members must be:

  • Age 21 or older
  • Living in Santa Barbara County
  • A CenCal Health member who has been identified with a cardiovascular condition
  • Willing to participate in the care plan and care services

Substance Use Disorder

The Substance Use Disorder program helps to improve the treatment and care for people with substance use issues.

The Substance Use Disorder Disease Management Program helps the member to find and access treatment for substance use disorder. Members enrolled in this program will work with a Registered Nurse to take back control of their lives. Participants will be assessed and an individualized care plan will be developed to help them improve their quality of life and manage their condition. The RN will work with the member via telephone to determine the needs and the resources that would be of the most benefit. CenCal Health provides care management and assists in arranging healthcare and mental health services with local agencies.

Program Goal:

To help our members get the care and treatment they need, at the appropriate level of care. For those willing, the goal is to guide members through the treatment and recovery process, to gain freedom from their SUD.

Program Objectives:

  • Educate members on SUD and treatment options.
  • Assist members to address related health conditions through primary or specialist care.
  • Educate members on the importance of coordinating care between providers.
  • Encourage the member to adhere to physician directed treatment plans.
  • Reduce the need for emergency care caused by active addiction.
  • Provide members/family with potentially lifesaving medication and instruct in appropriate use.
  • To educate members on options for Medication-Assisted Treatment (MAT) and identify a willing provider they will be able to work with.
  • Educate and guide pregnant women with SUD to get prenatal care and provide information on MAT to increase chances for a healthy pregnancy, when appropriate.
  • Educate family members on SUD and resources for support groups; identify potential support and provide contact names/numbers.
  • Support and empower the member to take ownership of their recovery.

Who can receive SUD Disease Management services?

To be eligible for these services, members must be:

  • Age 18 or older
  • A CenCal Health member with a primary substance use disorder, or a health condition that is effected or caused by a substance use disorder
  • Willing to participate in the care plan and care services

Diabetes

Program Goals: 

The main goals of the Diabetes Disease Management program are to increase member self-management of diabetes through education, in order to reduce complications and improve their quality of life.

Program Objectives:

  • Improve the quality of life for members with diabetes
  • Improve the quality of care in accordance with the ADA Standards of Medical Care
  • Improve coordination of care and adherence to treatment programs for members
  • Promote a patient interactive approach toward diabetes care by using interactive goals in care plans, facilitating patient-provider communication, and encouraging members to take a more active role in managing their condition
  • Encourage member adherence to provider prescribed treatment plans
  • Increase member self-management and knowledge of diabetes and management of symptoms
  • Improve compliance to diabetes nutrition and pharmaceutical therapies
  • Reduce exacerbations and secondary complications of diabetes

What Services can the Diabetes Disease Management Program provide?

  • Reminders and assistance with follow-up appointments to health care providers
  • Telehealth coaching and education from a CenCal Disease Management program RN
  • Referrals to community and government resources
  • Encourage and support Diabetes patient self-management
  • Provide nutrition and lifestyle counseling

Who is Eligible for the Diabetes Disease Management Program?

  • CenCal Health members 21 years and above, with a primary diagnosis of Diabetes