CMO's Disease Management Programs are designed to work hand-in-hand with primary care providers, specialists, pharmacists and members to create and manage treatment plans, to support patients with self-management skills training that empowers them to actively participate in improving the quality of their lives, and to add value across the healthcare delivery process.

The guiding principles of all of our Disease Management Programs are:

Establishing and maintaining a holistic patient view that understands the prevalence of patients having multiple conditions

Supporting the primary care physician

Providing nurse case managers with all appropriate resources (computer access, relationships with care facilities, etc.)

Directly involving the clinical pharmacist

Using remote monitoring techniques, as indicated

Demonstrating efficacy and impact of condition management techniques on utilization and cost

Creating an environment for enrollees that provides ongoing assessment, monitoring, education and follow-up

Patient Assessment
Once identified, patients are assessed by a CMO Nurse Case Manager who gathers information from both the patients and their physicians to establish baseline medical and general information that could impact treatment. A detailed assessment of patients is conducted that covers their condition and current health status, their understanding of their condition and relevant lifestyle choices, and addresses issues such as diet and nutrition, exercise, medication compliance, smoking and depression.

For most programs, patients are stratified into one of four severity levels based on three aspects of the clinical and allied status:

1. Clinical criteria specific for each condition, such as New York Heart Association classification criteria for heart failure;
2. The presence of complicating or associated co-morbid conditions, such as heart problems or depression in patients with diabetes; and
3. The presence of associated psychosocial needs.

Based on the classification of severity, the Nurse Case Manager can determine if more intensive interventions are necessary. For example, for high-risk diabetics with hypertension, treatment might include home visits, frequent eye and foot exams, and close communication with the physician.

Unifying Patients and Providers
CMO Nurse Case Managers work closely with physicians' offices to coordinate and oversee the compliance of each patient with specific treatment plans and to confirm overall adherence to the program. CMO's Nurse Case Managers provide timely, accurate and relevant communication with the physician regarding their patients' status and help the physician increase compliance with their plan.

Best Practice Guidelines
Creating a team of clinical experts in the development of health management strategies and protocols is critical to the success of any DM program. To this end, CMO develops and refines practice guidelines by convening multidisciplinary design and improvement teams of physicians, nurses, pharmacists, researchers and other clinicians with experience in a particular condition. These teams review, discuss and modify nationally recognized, disease-specific guidelines. They provide the medical and technical expertise to establish best-practice treatment guidelines and protocols.

Guidelines are available for Asthma (adult and pediatric), Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, Depression, Hyperlipidemia and Hypertension. To request an electronic copy of a guideline, send your request to providerrelations@cmocare.com.

Patient Empowerment
CMO provides patients with tools, information and educational materials on their condition to encourage them to take control of their condition and to embrace their role as a key member of the healthcare team. Frequently, the Nurse Case Manager uncovers areas within a patient's lifestyle that can be altered, improving the health of the patient.

Ongoing Monitoring and Support
Once the program is in place, the CMO Care Team monitors patient progress to help determine the effectiveness of interventions or changes in health status. Through this ongoing relationship, patients receive additional support and guidance.