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.
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
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
Asthma
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.
Refer Patient to Care Management
Call us at 866-853-5241 or complete the appropriate form to refer a patient to a Care Management program. Our care management staff will evaluate the member and enroll him/her in the most appropriate program based on condition, severity of illness and individual needs.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
- Asthma Guidelines (National Heart, Lung and Blood Institute)
- Pediatric Asthma Action Plans (Massachusetts Health Quality Partners or MHQP)
- Adult Asthma Action Plans (MHQP)
Behavioral Health
We partner with Carelon Behavioral Health to administer our behavioral health program for our members. To request prior authorization for behavioral health services, call Carelon at 866-444-5155 or visit their website.
Want to refer a patient for additional support?
If you have WellSense members 18 years and older whom you believe would benefit from behavioral health services or behavioral health care management, fill out the Care Management Referral Form and contact Carelon Behavioral Health (our Behavioral Health support) at 866-444-5155.
Need Help with a Patient?
PCPs can call our Physician Decision Support Line to discuss behavioral health issues with Carelon psychiatrists. Topics may include psychopharmacology, treatment alternatives and when to refer for a psychiatric assessment. To reach Carelon's Physician Decision Support Line, call 866-444-5155.
Additional Resources
- Behavioral Health toolkit for PCPs: Assists Primary Care Providers (PCPs) in the diagnosis and treatment of mental health and substance use disorders.
- MA Department of Health/Bureau of Substance Abuse Services: “Their future depends on you– Together we can prevent prescription drug abuse” brochure is now available for ordering and downloading. You’ll find roles that all community members can play to prevent prescription drug abuse.
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.
Antidepressant 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.
Our behavioral health partner, Carelon Behavioral Health, developed a series of tools and resources for medical providers that cover the important topic of geriatric depression. You can find those materials here:
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
- Adult Depression in Primary Care (Institute for Clinical Systems Improvement or ICSI)
- The Surgeon General’s Report on Alcohol, Drugs and Health (2016) (U.S. Department of Health and Human Services (HHS), Office of the Surgeon General)
- ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents (American Academy of Pediatrics or AAP)
- Alcohol Use Disorder (Carelon Behavioral Health)
- Alcohol Withdrawal (Carelon Behavioral Health)
- Guideline for Prescribing Opioids for Chronic Pain (CDC)
- Drug Abuse (NIDAMED)
- Drug Testing (Carelon Behavioral Health)
- Opioid Use Disorder (Carelon Behavioral Health)
- Opioid Use Disorder in pregnancy (American Society of Addiction Medicine)
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
Cardiovascular Health Resources (Million Hearts)
Refer Patient to Care Management
Call us at 866-853-5241 or complete the appropriate form to refer a patient to a Care Management program. Our care management staff will evaluate the member and enroll him/her in the most appropriate program based on condition, severity of illness and individual needs.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
Heart Failure Guidelines (ACCF/AHA)
COPD (Global Initiative for Chronic Obstructive Lung Disease)
Hypertension (AAFP)
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
- We make reports available to providers to help identify patient gaps. For example, providers can receive reports with patients’ HbA1c levels and lists of patients overdue for diabetic eye exams.
- 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.
Refer Patient to Care Management
Call us at 866-853-5241 or complete the appropriate form to refer a patient to a Care Management program. Our care management staff will evaluate the member and enroll him/her in the most appropriate program based on condition, severity of illness and individual needs.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
Standards of Medical Care in Diabetes (American Diabetes Association)
Pain and Medication Management
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 care is limited to the care and treatment of disorders of the spine and neck as well as cervicogenic headaches. We cover the following outpatient services when they are administered by a licensed chiropractor:
- Spinal manipulation
- Diagnostic x-rays other than magnetic resonance imaging (MRI), Computerized axial tomography (CT Scans), and other imaging tests
- Outpatient supportive medical treatment services.
If medically necessary, occupational therapy can be provided in the outpatient setting when applicable clinical review criteria are met. Therapeutic services provided by an occupational therapist would include:
- Therapeutic exercises (task-oriented activities designed to restore physical function, sensory-integrative function, functional status, and ability to complete ADLs)
- Compensatory techniques (i.e., used to improve the level of ability to perform ADLs such as teaching an amputee how to use a prosthetic device, teaching a stroke patient new techniques to perform ADLs, standing or balance training in order to perform ADLs following surgery, and/or restoration of the lost use of extremity to perform ADLs)
CBT challenges members to replace unhelpful or negative thoughts, feelings and actions with more functional behaviors and coping strategies to solve problems; in use with pain management, it teaches relaxation, mindfulness and physical adaption skills to cope with the occurrence of physical pain, as well as challenges the thoughts related to pain.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
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
- Access to a registered nurse skilled in obstetrics and newborn care for any needs relating to safe and healthy 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
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.
Providers Impacted by the Regulation
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.
Resources
| Type | Description |
|---|---|
|
Screening Regulations |
Learn more about the regulations on screening for postpartum depression |
|
Reporting Form |
You or your provider organization must complete and submit this form by no later than March 1 for the previous calendar year unless you fall within the exception to the rule for direct reporting to the Massachusetts Department of Public Health (MDPH). |
|
Screening Grid |
Postpartum depression screening tool provided by MDPH. |
Refer Patient to Care Management
Call us at 866-853-5241 or complete the appropriate form to refer a patient to a Care Management program. Our care management staff will evaluate the member and enroll him/her in the most appropriate program based on condition, severity of illness and individual needs.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
Perinatal Guidelines (MHQP)
- Screening and vaccination schedule tools
- Member newsletters
- Text messaging programs with healthy lifestyle tips
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
Refer Patient to Care Management
Call us at 866-853-5241 or complete the appropriate form to refer a patient to a Care Management program. Our care management staff will evaluate the member and enroll him/her in the most appropriate program based on condition, severity of illness and individual needs.
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
- Child and Adolescent Immunization Schedule by Age (CDC)
- Pediatric Preventive Health Guideline (MHQP)
- Bright Futures (AAP)
- Adult Preventative Care Guidelines (From the Massachusetts Health Quality Partners or MHQP) – SCO
- HPV educational materials (CDC)
Senior Care
We have provided a list of clinical guidelines that may apply to our Senior Care Options members.
Clinical Practice Guidelines
WellSense adopts, endorses and implements these evidence-based guidelines from national sources, professional organizations, or developed by regional collaborative groups. Guidelines serve as a means of establishing standards among medical and behavioral health providers to improve health outcomes. They are not intended to replace clinical judgment.
Additional Resources
- 988 Suicide and Crisis Lifeline
- Caring for Adult Patients with Suicide Risk (Suicide Prevention Resource Center)
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