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TRICARE Operations Manual 6010.62-M, April 2021
Clinical Operations
Chapter 7
Section 3
Population Health (PH) Care
Revision:  
1.0  PH CARE
1.1  The contractor shall, to the extent permitted by law and regulation, provide a whole-person PH focus that will utilize evidence-based practices, deliver person-centered interventions based on identified risk and needs, and will incorporate community resources within the constraints, boundaries, and benefits of the current TRICARE program.
1.2  The contractor shall describe their PH care goals that shall include maintaining or improving the physical, behavioral, and psychosocial well-being of the identified beneficiary, as well as address health disparities by incorporating cost-effective interventions tailored to meet the needs of the individual. For plan submission requirements, see DD 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract.
1.3  The contractor shall conduct an annual evaluation of the PH care delivered. A list of performance measures will be provided annually by the Government Designated Authority (GDA), 60 calendar days prior to the start of each option year. For reporting details, see DD 1423, CDRL, located in Section J of the applicable contract.
2.0  CHRONIC CARE (CC)/DISEASE MANAGEMENT (DM) PROGRAM
2.1  The contractor’s CC/DM Program, a part of PH, will apply current industry standards for population identification and methodology, identification of disease indicators including baseline metrics, risk stratification, intervention, care coordination activities based on stratification levels with targeted outcomes, care transition plans for hospitalized CC/DM participants, provider communication, and integration. The program shall incorporate nationally recognized evidence-based guidelines and protocols to include Department of Defense (DoD)/Department of Veterans Affairs/Veterans Health Administration (DVA/VHA) guidelines when available and appropriate.
2.2  The contractor shall collect and trend all required Healthcare Effectiveness Data and Information Set (HEDIS®) measures. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
2.2.1  The contractor shall ensure all HEDIS® data is audited by an auditing firm approved by the Government.
2.2.2  The contractor shall collaborate with the Government, no less than annually, to determine which HEDIS® measures are to be reported.
3.0  TARGETED HEALTH MESSAGING
3.1  The contractor shall communicate, collaborate, and coordinate with GDA to identify targeted health messaging opportunities for high-risk beneficiaries or high-cost procedures.
3.2  The contractor shall develop and implement a process to outreach to at-risk or high-risk beneficiaries, as well as, to beneficiaries with high-cost conditions.
3.3  The contractor shall execute targeted health messaging within 60 calendar days of high-risk or high-cost identification.
3.4  The contractor shall provide methods for communication, targeted messaging, access, education, and recommended medical and behavioral health care or other sensitive health diagnoses via electronic formats with interactive capabilities to all eligible beneficiaries for PH care and CC/DM programs. For plan submission requirements, see DD 1423, CDRL, located in Section J of the applicable contract.
3.5  The contractor shall incorporate telemedicine and related electronic mobile applications to, to the extent permitted by law and regulation, into their programs to encourage program participation and engagement.
3.6  The contractor shall report beneficiary engagement with electronic self-management, satisfaction, and program outcomes. The effectiveness of the electronic program format will be demonstrated via participation through telemedicine and/or use of apps, education, or outreach. For plan submission requirements, see DD 1423, CDRL, located in Section J of the applicable contract.
4.0  DISEASE PREVENTION AND HEALTH PROMOTION SERVICES
4.1  The contractor shall design and implement disease prevention and health promotion services (e.g., Diabetes Prevention) that address the full spectrum of lifestyle risks and promote healthy behaviors to improve the health of the TRICARE population and save costs for the Government. These programs shall be described in the Medical Management (MM) Annual Plan as part of the contractor’s PH care.
4.2  The contractor shall initiate a program that continually evolves to incorporate and maintain healthy lifestyle changes for high-risk or at-risk TRICARE-eligible beneficiaries. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3  Tobacco and Vaping Cessation
4.3.1  The contractor shall ensure all TRICARE-eligible beneficiaries have access to a toll-free quit line addressing tobacco and vaping, which will provide support and evidence-based guidance regarding tobacco and vaping use.
4.3.2   The contractor shall ensure the tobacco and vaping quit line are available at a minimum by telephone, chat and text.
4.3.3   The contractor shall ensure the quit line is staffed with personnel qualified to provide advice and counseling regarding evidence-based approaches to quit tobacco and vaping use, including but not limited to use of medication as part of tobacco and vaping cessation. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
4.3.4  The contractor shall ensure quit line personnel utilize motivational interviewing to assess stage of readiness for quitting and to encourage quitting.
4.3.5  The contractor shall inform all authorized providers (to include direct care providers) and beneficiaries by their preferred means of communication about the quit line and how to access those services at the start of healthcare delivery and then at least annually for the duration of the contract. This information shall also be provided to all Markets/Military Medical Treatment Facilities (MTFs).
4.3.6  The contractor shall obtain Government approval of all educational material related to the quit line prior to use.
4.3.7  The contractor shall provide a secure means for providers to notify the contractor of beneficiaries who may benefit from the quit line.
4.3.8  The contractor shall monitor claims at least quarterly for any beneficiary with a new diagnosis of nicotine dependence and ensure that the quit line proactively reaches out to any patient with a new diagnosis of nicotine dependence, or who has been identified by a provider for support from the quit line.
4.3.9  The contractor shall provide quit line services at no cost to the beneficiary and there shall be no limit to the number of times a beneficiary may utilize the quit line.
4.3.10  The contractor shall report quit line data to the Government. For reporting requirements, see DD Form 1423, CDRL, located in Section J of the applicable contract.
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