Care Management and Disease Management
You can refer your Aetna Better Health of New Jersey patients for care management or disease management services by calling 1-855-232-3596. You can also contact our inpatient concurrent review nurse for patients in an inpatient facility.
Identifying members for care management and disease management
We use the following sources to identify members for care management and disease management:
- Enrollment data from the state
- Predictive modeling tools
- Claim/encounter information including pharmacy data, if available
- Data collected through the utilization management process
- Laboratory results
- Hospital or facility admissions and discharges
- Health risk appraisal tools
- Data from health management, wellness or health coaching programs
- Providers referring members that are inappropriate, disruptive or threatening in the office
Do your patients have care management needs?
We can help your patients enhance their self‑management skills with chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes and other conditions. Our program is integrated with Case Management and Condition Management, so your patient has one care manager. We can help with assisting members increase their knowledge about how to be healthier and improve their health outcomes. Call or e‑mail the Integrated Care Management Team at:
Supervisor, Clinical Health Services
Ann Marie McGinnis
Supervisor, Clinical Health Services
We may also use referrals from our health information or special needs lines, members, caregivers, providers or practitioners to identify members appropriate for care management and stratification levels for case managed members.
Our care management department provides support to members based on each individual’s risks and unmet needs. These care needs are assessed by licensed nurses, social workers and counselors, as well as non-clinical professionals. We use a bio-psycho-social model (BPS) to help us identify what care our members need. Then, the integrated case manager performs a health risk assessment to determine the member’s medical, behavioral health and bio-psychosocial status.
Care managers collaborate with the member, member’s family, PCP, psychiatrist, substance abuse counselor or any other healthcare team member to achieve a quality-focused, cost-effective care plan. Care management educates members on their specific disease and how to prevent worsening of their illness or any complications. The goal is to maintain, promote or improve their health status.
Care management programs include, but are not limited to:
- Pregnancy outreach and high-risk OB
- Special health care needs
- Behavioral health/substance abuse
Call 1-855-232-3596 and ask for the care management department if you'd like more information. You can also refer one of your patients to care management.
Disease management and automatic enrollment
We offer disease management programs to members with specific medical conditions including:
- Chronic obstructive pulmonary disease (COPD)
- Heart failure (HF)
Members don’t have to enroll. We automatically enroll members when we identify them as having one of the above conditions. We’ll inform you of their participation and make sure that we work with you to reinforce their treatment plan. Our goal is to educate, support and prevent the disease from getting worse. We want to reduce hospitalization and high usage of health care resources by giving members the tools they need to better manage their health.
Our disease management programs help members stay healthy. Members learn about their diseases and how to stay well by working with their provider. Our program includes regular communications, targeted outreach and support, and focused education.
The conditions in our program include diabetes, asthma, chronic obstructive pulmonary disease (COPD) and heart failure, among others.
Call 1-855-232-3596 and ask for the case management department if you'd like more information. You can also refer your patients to our disease management programs.
Aetna Better Health of New Jersey performs Quality management (QM) through a Quality Assessment and Performance Improvement (QAPI) Program with the involvement of multiple organizational components and committees. The primary goal of the QM Program is to improve the health status of members -- or maintain current health status when the member’s condition is not amenable to improvement.
Aetna Better Health of New Jersey’s QM Program is a continuous quality improvement process that includes comprehensive quality assessment and performance improvement activities. These activities continuously and proactively review our clinical and operational programs and processes to identify opportunities for improvement. Our continuous QM process enables us to:
- Assess current practices in both clinical and non-clinical areas
- Identify opportunities for improvement
- Select the most effective interventions
- Evaluate and measure the success of implemented interventions, refining the interventions as necessary
Elderly and disabled members
Aetna Better Health has dedicated Care Management programs for our members who are elderly or disabled.
Members who are elderly, have disabilities or both (including those in Managed Long Term Services and Supports [MLTSS]) have special service needs and risks, such as:
- Need for additional services to improve and maintain quality of life
- Increased risk for institutionalization
- Increased risk of falls, injuries (including fractures) and adverse events
- Increased risk of cognitive impairment
- Higher prevalence of polypharmacy and medication interactions
- Risks for abuse, neglect and exploitation
- Higher vulnerability to influenza and pneumococcal disease
- Under-recognition and under-treatment of depression
- Need for cancer surveillance
We have special programs in place to enhance their quality of life and assure optimal health outcomes. This includes evidence-based guidelines you can find on our website, focused education of members, caregivers and providers and review of data that tells us how they are doing. The main goals of the program are to assure that these members get appropriate testing and care for their special needs, with emphasis on the following goals and objectives:
- Reduce avoidable complications of chronic illness, such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, hypertension and seizure disorders
- Support early diagnosis of cancers of the breast, cervix, colon and prostate
- Reduce injuries, pressure ulcers and aspiration pneumonia
- Reduce avoidable hospitalizations, including those that can be prevented by vaccination for influenza and pneumococcal disease
- Support early recognition of depression and cognitive impairment
- Prevent or reduce injuries
- Maintain quality of life and independence as much as possible
- Decrease or prevent long term institutionalization
- Prevent and identify abuse, neglect and exploitation
- Improve quality of care
- Assist caregivers with support and resources
National recommendations and educational materials are available through the National Institute of Health’s National Institute on Aging, found here:
In addition to frequently updated news items, there are multiple publications for physicians and other providers such as Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians, End of Life: Helping with Comfort and Care and multiple health topic booklets relevant to our members who are elderly or disabled. The link for Talking with Your Older Patient: A Clinician’s Handbook is found here.
We hope you find these materials helpful and look forward to continued collaboration with practitioners and providers to enhance the well-being of these members.
Patients can experience falls in the home, workplace and acute‑care setting as well as in long‑term care facilities. It’s important to acknowledge the impact of falls on patients.
- Patients age 85 and older are up to 15 times more likely to sustain hip fractures from falls than patients age 60‑65 years.
- Falls are the leading cause of fatal injury and the most common cause of non‑fatal trauma‑related hospital admissions among older adults.
The elderly are more vulnerable to falls than any other age group. However, all members can benefit from education regarding precautions to make homes, hospitals and workplaces safe and free from falls.
Patient use of certain prescription medications and polypharmacy may make patients unsteady, possibly leading to falls. Reviewing your patient’s medications with them and suggesting the following precautions can help prevent falls from happening:
- Wear sturdy shoes that have non‑slip soles
- Always use a handrail when climbing up or down stairs
- Keep doorways and floors free of obstacles such as throw rugs and furniture
Prenatal Risk Assessment (PRA)
Aetna Better Health of New Jersey would like to inform you about State law P.L.2019, c.88 that mandates the completion of the PRA form for pregnant women receiving state-supported Medicaid health coverage.
The law began in the state Legislature as Senate Bill 3406 as a package of bills designed to improve the health of expectant mothers and newborns. The goal is to decrease increasing rates of maternal and infant mortality in New Jersey. The PRA form is now required documentation for all uninsured, Medicaid presumptively eligible, and Medicaid eligible prenatal patient. This law impacts obstetrical providers, nurse midwives, and other licensed healthcare professionals.
What do OB Providers need to do?
OB Providers will need to submit the required PRA form to be reimbursed for OB services. If the forms are not received, payment may be impacted.
Please follow the steps and register below to submit the PRA Forms:
Complete and submit the initial visit, follow-up visit and third trimester visit PRA forms. The initial visit PRA form should be completed during the first prenatal visit, the follow-up PRA form when there is a change in insurance or maternal risk factor identified and the third trimester form at 30-36 weeks gestation. All prenatal care providers must register with Family Health Initiatives (FHI) in order to access the PRA/SPECT.
Register online at http://praspect.org or call 1-856-665-6000. New users must register by calling FHI at 1-856-665-6000 or emailing PRA@FHIworks.org. PRA forms are submitted by logging into http://praspect.org.