Managing ongoing health conditions can be challenging. There’s a lot to learn, and you may have questions. We're here to help. Our program is designed to support you every step of the way, from understanding your diagnosis to managing your condition to achieve your health goals.
What is the Health Management Program?
The Health Management Program is a free program designed to help you manage your ongoing health condition, such as heart failure, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes, or frailty. Our team of registered nurses, health educators, and coaches will work with you to provide personalized support and education to help you manage your condition and improve your overall health.
Who is eigible for the Health Management Program?
You may be eligible for the Health Management Program if:
• You have been diagnosed with one or more chronic conditions (CHF, COPD, CAD, Diabetes, Frailty)
• You have a high-risk score based on predictive modeling
• You have recently been hospitalized (within 30 days) with a diabetes or respiratory diagnosis
• You are transferring from another program, such as Complex Care, Unplanned Care, or Readmission Prevention
What services does the Health Management Program offer?
Our program offers a range of services to support you in managing your chronic condition, including:
• Telephonic coaching and support from our team of registered nurses, health educators, and coaches
• Disease-specific education to help you understand and manage your condition
o Diabetes
Diabetic Educators and Registered Dietitians Nutritionist can help you better manage your diabetes.
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o Asthma
Our Respiratory Support Team can help you learn about proper use of inhalers and breathing equipment to breathe and sleep better.
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• Self-management support to empower you to take an active role in managing your condition
• Goal setting and action planning to help you achieve your health goals
o Certified Health Coaches are specially trained to educate and support your weight-related goals, exercise goals, smoking cessation or any other health-related goals.
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• Care coordination with your health care providers to ensure comprehensive care
• Resource identification and referral to community resources and support groups
• Transition support if you are transferring from another program
• Progress monitoring and evaluation to track your progress and ensure the program is meeting its goals
What to expect: getting started
If you are eligible for the Health Management Program, you’ll receive a phone call from our team to introduce the program and answer any questions you may have. We will work with you to schedule regular phone calls to provide coaching and support. Our program typically lasts for 6 weeks to 3 months, with regular outreach every 10 business days.
We’re here to help you manage your ongoing health condition and improve your overall health and well-being.
If you're living with multiple chronic conditions, recovering from a serious health issue or injury, or managing a rare or complex disease, you may need extra support to navigate your care. Our team will work closely with you and your health care providers to develop a personalized care plan that addresses your specific needs and helps you achieve your health goals.
What is the Complex Care Program?
The Complex Care Program is a self-management support program for members with ongoing health conditions. It uses intensive coaching to help members achieve a higher level of wellness and independence. Our goal is to help you manage your conditions and improve your overall health.
Our teams also works closely with members who have serious and complex injuries or other complex conditions that require special care to help them navigate their care and improve overall health.
Who is eligible?
You may be eligible for the Complex Care Program if:
• You have multiple chronic conditions, such as diabetes, heart disease, or lung disease.
• You have been in the hospital or had a serious health issue recently.
• You need help managing your conditions and staying healthy.
You may be eligible for specialized care management if you have a serious condition such as:
• Severe injuries or illnesses, like amputations or severe burns
• Certain types of cancer or diseases, like HIV/AIDS or Parkinson's
• Rare diseases, like ALS or sickle cell disease
• Other complex conditions that require special care
What services do we offer?
Our program offers:
• A comprehensive assessment to understand your health needs.
• A personalized care plan.
• Regular check-ins with a nurse to monitor your progress.
• Help with transportation, financial, or other social needs.
• Support to help you make healthy lifestyle changes.
Members who need more specialized care may also receive:
• Help coordinating your care including managing your medications and treatment plans.
• Education and consultation from specialists, like respiratory therapists or dietitians.
What to expect: getting started
If you're eligible for the program, you'll be contacted by our team to discuss your care plan. We'll work with you to:
• Complete a comprehensive assessment to identify and understand your needs.
• Create a personalized care plan to manage your condition.
• Set goals and priorities for your care.
• Regular check ins with you regularly to see how you're doing.
Returning home after a hospital stay is a significant milestone, and with the right support and guidance, you can set yourself up for a successful and speedy recovery.
What steps can I take to help recover at home after a hospital stay?
Understand your hospital discharge instructions:
Make sure you ask your doctors and nurses at the hospital any questions you have about your discharge instructions. Take notes and ask if there is a nurse you can call if you have any questions.
Manage your medications:
Review your medication list with your doctor and ask about any changes or new medications. Make sure you understand the dosage, frequency, and potential side effects. Do you struggle to take your medication on time? Taking your medication as directed is crucial for your treatment to be effective. Try these tips:
• Use a pill organizer.
• Set reminders, like an alarm on your phone, or mark your calendar.
• Ask a friend or family member for help. Have them call or text you when it’s time to take your medication.
Make an appointment with your primary care doctor:
Schedule an appointment with your doctor as soon as you get out of the hospital. Update them on your hospital visit and make sure any new medications or treatments will work well with any existing prescriptions you have. Seeing your doctor right away after a hospital visit is one of the best ways to avoid a return trip.
Monitor your condition:
Report any changes in how you feel to your doctor. Also, if you are taking any new prescription medications, make sure to keep track of any side effects you may feel. Try keeping a symptom journal to track how you feel.
Stay connected to your doctor:
Maintain open communication with your health care team to address any concerns or questions you may have. Don’t wait to ask questions or report any concerns you have. Also, make sure to attend all your follow-up appointments.
Ask for help when you need it:
Recovering from a hospital stay can be challenging, both physically and emotionally. Don't be afraid to seek support from family, friends, or support groups.
Our Readmission Prevention Program
We’re here to help. Our readmission prevention program is designed to support you every step of the way, providing you with the tools and resources you need to recover safely and effectively at home.
What is the Readmission Prevention Program?
The Readmission Prevention Program is a special program designed to help you stay healthy and avoid going back to the hospital after you've been discharged. Our goal is to support you in managing your condition and preventing future hospitalizations.
Who is eligible for the Readmission Prevention Program?
You may be eligible for this program if you've recently been in the hospital and are at risk of being readmitted. Our team uses a special tool to identify members who may benefit from this program.
What services does the Readmission Prevention Program offer?
Our program offers a range of services to support you, including:
• A Transition of Care Assessment to help us understand your needs
• Education on how to prevent readmissions and manage your condition
• Hospital visits or home visits with a Registered Nurse Case Manager
• A personalized Care Plan to help you:
• Follow your discharge instructions
• Take your medications as directed
• Monitor your condition
• Know what to do if you have symptoms or concerns
• Referrals to other programs if you need ongoing support
What to expect: getting started
If you're eligible for the program, a Registered Nurse Case Manager will contact you by phone or visit you in the hospital or at home. They'll work with you to create a personalized Care Plan and provide education and support to help you manage your condition.
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Your mental well-being is just as important as your physical health. Your Florida Blue Medicare plan includes support from a team of behavioral health and mental health clinicians who will help you get the care you need to be your best self.
What is the Behavioral Health Program?
Our Behavioral Health Program is a special service designed to help you manage your mental well-being and substance use. Our team of experienced case managers will work with you, your family, and your health care providers to create a personalized plan to help you achieve optimal health and wellness.
Who is eligible for the Behavioral Health Program?
If you're struggling with mental health or substance, use issues, you may be eligible for our program. Our team will work with you to determine if this program is right for you.
What services does the Behavioral Health Program offer?
Our program offers a range of services to support your mental health and wellness, including:
• Comprehensive assessments to understand your needs and goals.
• Personalized care planning to address your medical, behavioral, and social needs.
• Care coordination to ensure that all your healthcare providers are working together.
• Patient education and support to help you manage your condition.
• Crisis intervention and emergency services when you need them.
• Connection to community resources, such as housing and employment services.
• Peer support groups to connect you with others who understand what you're going through.
What to expect: getting started
If you're interested in joining our Behavioral Health Program, here's what you can expect:
• A comprehensive assessment to understand your needs and goals
• A personalized care plan that addresses your unique needs
• Regular check-ins with your case manager to monitor your progress and adjust your plan as needed
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Good health is about more than just medical care. We help connect you to local resources to address social barriers to care.
What is the Community Health Program?
The Community Health Program is designed to help you get the care and support you need to stay healthy. Our team of Community Health Workers (CHWs) work in collaboration with our clinicians to connect you with local resources, address social and emotional challenges, and help you manage your health through outreach, education, and advocacy.
Who is Eligible for the Community Health Team Program?
If you're a member of our health plan, you may be eligible for the Community Health program. Our team will reach out to you to see if you're a good fit for the program.
What services does the Community Health Program offer?
Our program offers a range of services to support your health and well-being, including:
• Help finding local resources to address social and emotional challenges.
• Support with scheduling appointments and managing your health.
• Help navigating the health care system and accessing routine screenings.
• Case management to connect you with resources for ongoing care.
• Collaboration with your health care providers to ensure seamless care transitions.
• Community outreach and engagement activities to increase awareness of health-related issues and promote healthy behaviors.
What to expect: getting started
If you're eligible for the program, our team will reach out to you to introduce themselves and explain the program in more detail. They'll work with you to identify your needs and develop a personalized care plan.
Our Kidney Health Management program offered through Healthmap identifies chronic kidney disease (CKD) early.
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Advance Care Planning is an important step in ensuring that your healthcare wishes are respected and your loved ones are prepared to make decisions on your behalf if you become unable to communicate.
What is Advance Directive Planning?
Advanced Directive Planning is the process of making decisions about the medical care you would want to receive if you become unable to communicate or make decisions for yourself. It involves creating a set of instructions, often in the form of written documents, that outline your wishes for end-of-life care, medical treatment, and other healthcare decisions. It is part of a bigger program that includes different types of care management, such as case management, health management, and behavioral health.
Advance directives are legal documents that can include:
• A living will, which specifies the types of medical treatment you want or don't want
• A durable power of attorney, which appoints someone to make medical decisions on your behalf
• Other documents that outline your wishes for end-of-life care, organ donation, or other medical treatments
Why is Advance Directive Planning Important?
This program is important because it allows you to:
• Make informed decisions about your care
• Ensure that your wishes are respected
• Reduce stress and uncertainty for your loved ones
• Improve your quality of life
What Services Does the Program Offer?
The program offers many services to support Advance Directive Planning, including:
• Education about care planning and coordination
• Support from a dedicated Care Manager
• Connection to community resources and services
• Support for managing chronic conditions
• Behavioral health support
What to expect?
A care manager will work with you to:
• Discuss your values, goals, and preferences
• Explore your advance directive options (e.g., living will, durable power of attorney)
• Provide ongoing support and guidance
• Connect you with local community resources
Eligible members receive medication education to help obtain better results.
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