Patient care

Learn about our population health, disease management, and condition management programs, along with additional treatment tools available to help you support your patients.

 

Clinical practice guidelines

In order to help improve clinical outcomes, various clinical organizations have developed the evidence-based guidelines below. The guidelines are not intended to replace clinical judgment.

If you would like hard copies of any guidelines, please contact your Provider Relations representative.

Behavioral health clinical practice guidelines

Member support

WellSense provides ongoing education to members with asthma to help them manage their conditions more effectively.

We teach members about their asthma so that they can make decisions that reduce their exposure. This includes teaching members to:

  • Use quick relief and long-term inhalers correctly
  • Know their asthma triggers and how to avoid them
  • Work with their doctor to develop an Asthma Action Plan
  • Refill prescriptions in a timely manner
  • Educate parents how to manage and monitor their child’s asthma
  • Care Management

Our Care Management program can help members learn more about their asthma, including what triggers it, how medication can help, and how to live with it.

  • The asthma program includes provider reports with members’ medication histories for controller and rescue medications.
  • Any time a member is referred to one of our care management programs, we will notify you by letter or telephone and work to coordinate your patient’s care.

Provider toolkit

We believe that integrated, whole-person care is critical to successful health outcomes. As a healthcare provider, you may be the first point of contact for members with behavioral health concerns. Use our Behavioral Health toolkit to help identify and treat members needing behavioral health support.

Medication management

Non-adherence to antidepressant medication is a major barrier in the successful treatment of depression. If any of your patients who have newly-prescribed antidepressant medications are having trouble with their medication, we offer the following tips to help you increase patient compliance and increase the successful treatment of depression:

  • Give clear instructions about the new medication, including what the medication is for, how to take it correctly, and how long to take it for.
  • Tell your patient that it may take a few weeks before the medication starts to work and it is important not to stop taking it; explain that you may need to adjust the dosage or change medication to get the desired result over time.
  • Suggest your patient use a pill box and take the medication at the same time every day to build a routine; direct your patient to call us and we can provide a pill box at no cost.
  • Discuss possible side effects and advise your patient to call your office if they have any, or with any questions or concerns.
  • Schedule a follow-up visit to monitor your patient's progress; discuss compliance with medications at every visit.
  • If your patient is pregnant or breast feeding, assure her that the antidepressant prescribed is safe to take.

Additional resources

We offer Care Management programs for members with Congestive Heart Failure, Hypertension, Coronary Heart Disease, and COPD to help them manage their conditions.

Resources

WellSense provides education to members to help them manage their diabetes more effectively through preventive measure and awareness. We also work closely with members who need a little more help and guidance to navigate their condition.

Our goal is to teach members how to effectively manage their condition through ongoing education and targeted interventions. This approach helps members to:

  • Understand their diabetes and how they can adjust their lifestyle to improve outcomes, using our Diabetes toolkit
  • Acquire tools that help them track their numbers, including annual diabetes calendars and self-management checklists
  • Receive assistance and reminder calls, including help coordinating transportation to appointments
  • Seek referrals to Behavioral Health providers

Making sure that our members are using their medications safely and effectively is one of our top priorities as a health plan. Here are some resources that you may reference to help support you as your patients manage their pain with and without the use of prescription drugs.

Alternative Pain Management

WellSense offers several alternative methods for treating pain that do not require prescription medications. Some of the options available to members of our plan include the following:

  • Chiropractic services
  • Physical therapy services
  • Cognitive/Behavioral therapy services

Our Sunny Start! program provides education and support to help moms and babies get the care they need before, during, and after birth. This Care Management program provides:

  • Customized care planning by our care coordinators for low risk pregnancies or our registered nurses for moderate or high risk pregnancies
  • Free car seats and diapers for qualifying MassHealth members
  • Childbirth education classes to help prevent preterm labor and delivery
  • Postpartum reminder calls and newborn care information
  • Help finding community resources like WIC, housing, legal assistance, shelter, clothing

WellSense encourages members to pursue healthy lifestyles through physical activity, healthy eating, and keeping up-to-date on all necessary screenings and vaccinations. Tools developed to support members include:

  • Screening and vaccination schedule tools
  • Member newsletters
  • Text messaging programs with healthy lifestyle tips
  • Preventive care webpage

Screening

Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

Behavioral health screens are a normal and integral part of comprehensive well-child care. Along with MassHealth, we require primary care providers to offer a behavioral health screen to all MassHealth members under age 21 at every well child visit as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) schedule. You'll find information, resources and the list of the MassHealth-approved screening tools. For additional resources, visit the MCPAP website.

Health care providers are now required to annually submit data on screening for postpartum depression. Annual reporting is required by a provider that conducts or oversees screening for postpartum depression using a validated screening tool, during a routine clinical appointment in which medical services are provided to a woman who has given birth within the previous six months.

The providers responsible for adhering to these regulations are OB-GYNs, Family Medicine Practitioners, Advanced Practice Nurses including Nurse Midwives and Nurse Practitioners, and Physician Assistants, who practice in a family medicine/OBGYN setting.

WellSense encourages you to conduct and document age appropriate counseling on an annual basis for nutrition and physical activity. Please use the following codes to document the activities during your patient encounters. Appropriate coding may impact the records requested during future HEDIS reviews.

Description CPT ICD-10-CM Diagnosis HCPCS
BMI Percentile   Z68.51, Z68.52, Z68.53, Z68.54  
Counseling for Nutrition 97802-97804  Z71.3 G0270, G0271, S9449, S9452, S9470
Counseling for Physical Activity    Z02.5 S9451  


BMI Percentile

Documentation must include height, weight and BMI percentile. Either of the following meets criteria for BMI percentile:

  • BMI percentile
  • BMI percentile plotted on age-growth chart

Counseling for nutrition:

  • Discussion of current nutrition behaviors (.e.g., eating habits, dieting behaviors)
  • Checklist indicating nutrition was addressed
  • Counseling or referral for nutrition education
  • Member received educational materials on nutrition during face-to face visit
  • Anticipatory guidance for nutrition
  • Weight or obesity counseling

Counseling for physical activity:

  • Discussion of current physical activity behaviors (e.g. exercise routine, participation in sports activities, exam for sports participation)
  • Checklist indicating physical activity was addressed
  • Counseling or referral for physical activity
  • Member received educational materials on physical activity during a face-to-face visit
  • Anticipatory guidance for physical activity
  • Weight or obesity counseling

Care management and disease management

We provide programs for members with chronic and complex medical and behavioral health conditions, and those with socioeconomic barriers. Our goal is to help members and their providers better deal with their conditions, follow prescribed treatment plans, and prevent additional complications.

Care management programs may include care coordination; support of patient-centered medical homes and health homes; non-emergency medical transportation; wellness and prevention programs; chronic care management (disease management) programs; high cost/high risk member management programs, pregnancy programs and a special needs program.

If a member agrees to participate in any of our Care Management programs, a care manager will notify you by letter or telephone and work to coordinate your patient’s care.

Complex care management targets the most complex, highest risk members, including those with special health care needs for which a multidisciplinary approach is utilized:

Medical conditions that may be appropriate for a care management referral include, but are not limited to:

  • Cancer
  • Bariatric surgery
  • HIV
  • CVA or other degenerative neurological or neuromuscular disorders
  • Spinal cord injury/traumatic brain injury/anoxic brain injury
  • Complex newborn/NICU stay
  • Neonatal abstinence syndrome/shaken baby syndrome

Indications that a patient may benefit from a referral to Complex Care Management for any medical condition (including one managed through a population based program) include, but are not limited to:

  • An illness or event that has caused a change or decline in ability to self-manage
  • 5 or more chronic condition medications
  • 5 or more different specialists
  • An acute inpatient stay with LOS>7 days
  • Multiple admissions/readmissions
  • Multiple or repeated emergency department use
  • Homelessness, poor or inadequate living environment