Matria Disease Management Clinical Summary

Why Matria? | How the Program Works | Matria Outcomes

Why Matria?

Matria Healthcare offers the industry’s most comprehensive disease management program for all major chronic conditions:

• An unmatched technology platform that compiles data from multiple disparate systems to identify individuals who have a chronic condition or who are at risk for developing one
• Disease-specific intervention programs customized to improve patient accountability, increase patient knowledge about their disease and monitor and assist in care plan compliance
• The ability to handle large populations from a broad range of workforce settings – white collar and blue collar
• Industry leading cancer management capable of managing 40 different types of cancers
• Skilled clinicians that specialize in specific chronic conditions
• Educational and preventive services for individuals at risk for developing a chronic condition

How the Program Works

Matria Disease Management assists individuals with chronic diseases to better manage their conditions by increasing their knowledge about their illnesses, potential complications and importance of medication and treatment compliance. Our specialized nurses proactively contact patients to provide guidance and education, monitor their progress and ensure they are following the plan of care set by their physician.

Our clinical interventions were developed based on industry-accepted behavior modification principals. Each contact with a patient is customized based on the severity of the condition and the patient’s willingness to change unhealthy behaviors. Our programs have demonstrated that this approach to managing patients with chronic diseases and episodic conditions improves their overall health while reducing overall healthcare costs.

Our program follows a four-step process:

Step 1. Identify Participants

The first step is to identify individuals who have a medical condition or are at risk for developing a costly disease. This process requires sophisticated technology that can process large amounts of data from multiple sources.

Matria Healthcare has developed the industry’s most advanced disease management technology, called TRAX. The system integrates information from multiple sources, including claims data, pharmacy prescriptions, lab results, ER visits and hospitalization information.

TRAX technology identifies individuals with chronic conditions, stratifies them according to level of severity and develops a complete clinical record and treatment history. TRAX also uses predictive modeling tools to identify patients at risk for significant medical problems in the future – events that can result in substantial medical costs.

Step 2. Develop Customized Care Plans

A Matria health specialist contacts the employee by phone to conduct a multicondition risk assessment. Their responses are used to build a detailed clinical profile in the TRAX system and develop an individualized intervention program in conjunction with their physician designed to meet their specific healthcare needs.

Some patients may only need educational materials while other may require close one-on-one patient management. The programs are designed to ensure patient compliance to a doctor’s plan of care in accordance to national clinical standards.

Step 3. Support Patients in Managing a Health Condition

Once patients are identified and enrolled, Matria’s TRAX technology plays an important role in coordinating patient care. The system organizes information flow between patients, providers, employers and insurers.

The system coordinates regular physician visits, customized education and phone counseling from nurse specialists. It also tracks medication usage and patient compliance in order to give doctors critical information needed to better manage their patient’s health.

Patients have access to specially-trained registered nurses, dieticians, pharmacists and educators 24 hours a day – whether they need support with a medical issue, help following a doctor's treatment plan or guidance with medications. Nurses also proactively contact patients on a regular basis, as necessary, to support the patient in managing a condition.

Step 4. Generate Reports for Outcomes Analysis

Matria's disease management programs place a high strategic value on quality outcomes reporting to help our clients accurately measure the efficiency and effectiveness of their programs. Program evaluation includes the measurement and management of medical costs, pharmacy costs, hospital stays, ER usage, plus numerous physiologic and psychosocial parameters that serve as markers of clinical status, quality of life, functional status and recidivism.

Matria’s disease management programs often deliver cost savings and compliance improvements within a few months of implementation.

Matria Outcomes

Visit the Resource Center for disease-specific outcomes.