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 were developed to provide physician-based 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 primary care physicians and specialists to improve clinical outcomes, reduce or delay long-term complications, and improve their health and well-being. 

Successful Management Always Requires A Team (SMART) 

CenCal Health's Disease Management Programs follow the SMART framework. Our SMART programs include:

  • Diabetes SMART 
  • Heart SMART 
  • Breathe SMART 

See below for more information about each individual program. 


Diabetes SMART

Program Goal: 

CenCal Health’s Diabetes SMART Program is a disease management program for members diagnosed with diabetes. The goal of the program is to identify diabetic members and provide their Primary Care Physician (PCP) with tools to improve their quality of life by ensuring that they receive clinically appropriate care to manage their diabetes.  The objective of the program is to promote and facilitate patient-physician communication utilizing an interactive approach toward the treatment of diabetes by assuring receipt of appropriate medical services in accordance with established clinical practice guidelines.

Program Components: The Diabetes SMART Program is structured to support the management of members’ diabetes care by their PCP. The components of the program include:

  • Diabetes education materials for members upon request
  • Notification to PCPs of members newly enrolled in the Diabetes SMART program
  • Notification to PCPs of members’ need for clinically appropriate screenings related to diabetes care
  • Notification to PCPs of high risk diabetic members
  • PCP quality performance reporting regarding their diabetic population
  • An online tool to submit clinical data and to manage members enrolled in the Diabetes SMART Program via the web portal

Reports: All provider notifications regarding members enrolled in the Diabetes SMART program and PCP quality performance is communicated through quarterly reports submitted to PCPs.

Pay for Performance:

A $50 incentive is paid to PCPs for each assigned member identified with diabetes who annually completes all three minimum clinical services (MCS):

  • Hemoglobin A1c testing (HbA1c) 
  • Diabetic Eye Exam
  • Treatment or screening for nephropathy (Micro albumin urine test or total urine protein, ACE/ARB Rx, dialysis or referral to nephrologist.)

An additional $25 incentive is paid for each clinical improvement:

  • Hemoglobin A1c tests that show a 10% reduction from 1st baseline test within a calendar year (maximum of 3)

Breathe SMART

Program Goal:

CenCal Health’s Breathe SMART Program is a disease management program for members diagnosed with persistent asthma. The goal of the program is to increase the knowledge of members with persistent asthma and improve adherence to recommended treatment to reduce exacerbations, ED visits and hospitalizations. The objective of the program is to promote and facilitate patient-physician communication utilizing an interactive approach to better assure receipt of appropriate medical services in accordance with established clinical practice guidelines.

Program Components: The Breathe SMART Program is structured to support the management of members’ asthma by their PCP. The components of the program include:

  • Promotion of Action Plans for all members with persistent asthma
  • Informing Primary Care Providers with reports on preferred and rescue medication usage to assist coordination of care
  • Reporting to providers to identify patients with Emergency Department or Inpatient Stays, to enable intensive interventions to prevent readmissions

Reports: All provider notifications regarding members enrolled in the Breathe SMART program and PCP quality performance is communicated via quarterly reports to PCPs.

Pay for Performance: A $100 Incentive Bonus is paid to providers for each patient who meets the goal of filling 8 or more preferred asthma medications in a calendar year.

An additional $75 incentive is paid for an Asthma Action Plan for each member annually.

Spirometry tests are encouraged for Asthma patients as they may identify the degree of airflow obstruction that is poorly recognized or perceived by the patient, establish a diagnosis of asthma, and assess reversibility, severity or prediction of future adverse events. 

Heart SMART

Heart SMART helps to improve the treatment and care for people with Congestive Heart Failure and Coronary Artery Disease.

Heart SMART 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