Helping members manage psychosocial issues
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Helping members manage psychosocial issues

Improving personal health and resolving challenges that members may be facing is easier with a team by their side.

The Personal Health Management Program is an integrated behavioral and medical condition management program that teaches members how to manage their health conditions day-to-day and over the long term. It is available at no cost to EOCCO members for up to 12 months. The program focuses on the most vulnerable populations, including multi-chronic patients with psychosocial issues that affect their ability to follow treatments plans, access appropriate care, and make lifestyle changes.

Working closely with a team of licensed behavioral health clinicians and also physicians, participating members can:

  • Learn how to communicate more effectively with their doctor and arrive more prepared for their doctor visits
  • Make fewer unplanned calls to the office
  • Achieve higher treatment adherence rates
  • Have a decrease in emergency room visits and admissions
  • Connect and follow through with community resource referrals

Working together to manage their health

Participating members work with a personal clinician to better understand their health. Through regular phone calls, members get tools and learn techniques to manage their health. They also work with an outreach coordinator, who is a local resource that builds collaborative working relationships to support the clinical process between the patient and the personal clinician. The outreach coordinator also connects patients with community resources and contacts for support.

Impact of the program

There are measurable results from participating in the Personal Health Management Program. The efforts that will be made to impact the patient’s life include:

  • 8-12 sessions over 9-12 months
  • Progressive, action-inducing interventions in each call that build upon one another
  • Helping patients understand their care plan
  • Person goal achievement including the medical and behavioral health of the patient, as well as lifestyle choices
  • Closing gaps in healthcare effectiveness, through education and provider communication
  • Reduced emergency department utilization

Who qualifies for the program?

EOCCO members, ages 18 and older, may qualify for the Personal Health Management Program. They cannot have Medicare as primary insurance. One or more of the following conditions listed below enables members to begin managing their health:

  • Asthma
  • Chronic Back Pain
  • Chronic Kidney Disease
  • Chronic Obstructive Pulmonary Disease
  • Congestive Heart Failure
  • Coronary Artery Disease
  • Crohn’s Disease
  • Depression
  • Diabetes
  • Epilepsy/Seizures
  • Hypertension
  • Migraines
  • Multiple Sclerosis
  • Osteoarthritis
  • Parkinson’s Disease
  • Rheumatoid Arthritis
  • Ulcerative Colitis

Members who speak any language may enter!

How to refer patients to the program

Providers or care team members can refer EOCCO members to the Personal Health Management Program by filling out a one-page program referral form.

Please email the outreach coordinator at to schedule a time to review the program and get answers to any questions you and your team may have.

Learn more by downloading any of the following documents:

  • Provider presentation
  • Brochure
  • Patient flyer
  • Referral form