Care Management In partnership with your primary care provider, you have access to additional resources to meet your health goals. A care team will work closely with physicians to provide the care needed for individuals with chronic diseases such as diabetes, high blood pressure, heart failure and asthma. The entire care team will work together to provide seamless care, will help individuals navigate the health care system and get connected with the resources needed to better manage their disease. Below are a couple of the focus areas and the bene昀椀ts available for health plan members who qualify: Transition Care Targets patients who are discharged from the hospital and have previously been identi昀椀ed as having a high likelihood of readmission within 30 days. Complex Care Targets patients who are living with complex chronic conditions, such as hypertension and diabetes, and are at high risk for either an emergency or inpatient encounter. Diabetes Management Program Disease management is a con昀椀dential program provided by FMOLHS to help you or a covered dependent living with a chronic condition. Diabetes coaching is available through Healthy Lives. Eligible team members and dependents will have access to a personal health coach and together develop achievable goals and strategies for improving their overall health. When you work with a nurse coach, you’ll get tips and practical tools for managing your chronic condition. They will also help you set up a plan to reach personal goals. Coaching is a great way to re-energize yourself to improve or manage your condition. Maternity Management In partnership with your health care provider, a Healthy Lives registered nurse will assist you throughout your pregnancy with your personalized health needs. Maternity management nurses will have personal contact each trimester and provide 昀椀rst year of life education. Individuals engaged in maternity management receive free preconception counseling and prenatal information. 31