Member Centered Programs

SFHP Disease Management Programs

San Francisco Health Plan offers two, no-cost disease management programs:

  • SFHP Asthma Care Program
  • SFHP Diabetes Care Program

These programs provide a comprehensive, ongoing, and coordinated approach to improving health outcomes for SFHP members with asthma and diabetes. SFHP’s Disease Management Programs draw upon NCQA program best practices, and utilize evidence-based practice guidelines in the development of program content:

San Francisco Health Plan members who qualify are automatically enrolled in these programs, and may opt out of services at any time. Components of the programs include:

  • Enhanced health education for all members by mail (welcome packet containing health education booklet and program information) available in English, Spanish, Chinese, and Vietnamese. Additional resources may be mailed to members with identified health education or behavioral health needs.
  • Annual incentive opportunities. This includes one $25 incentive for members with asthma for completing an Asthma Control Test. Members with diabetes can qualify for two $25 gift cards when they complete the following screenings: 1) HbA1c test, blood pressure check, and monitoring for nephropathy (ACE/ARB or urine screening), and 2) diabetes eye exam (dilated or retinal exam).
  • Two annual check-in calls per year for members with greater needs. The first call includes a basic health education assessment, and the second provides a reminder to receive chronic condition screenings.
  • A warm transfer to the PCP’s office for members who indicate they would like to make a PCP appointment during the check-in call.
  •  The option to sign up for SFHP’s asthma and diabetes texting programs.

Below is additional information about each program and what you can do to help your SFHP patients who qualify.

AsthmaDiabetes

Who is eligible? 

  • SFHP Medi-Cal members
  • Healthy Kids HMO
  • Healthy Workers HMO
  • Ages 4+

Who is eligible? 

  • SFHP Medi-Cal members
  • Healthy Workers HMO
  • Ages 18+

What materials do my patients receive from SFHP? 

  • Asthma Control Test incentive form.
  • “Take Charge of Your Asthma” health education booklet.
  • Welcome letter.

What materials do my patients receive from SFHP? 

  • Diabetes screening test incentive form.
  • Diabetes eye exam incentive form.
  • “Take Charge of Your Diabetes” health education booklet.
  • Welcome letter.

What if I have questions? 

What if I have questions?

What can I do as a physician? 

  • Work with your patient to complete an asthma action plan. A template is available in the “Take Charge of Your Asthma” booklet.
  • Complete an asthma control test annually with your patient. Sign off so that they qualify for a gift card.
  • Review clinical practice guidelines to improve assessment and treatment of asthma.

What can I do as a physician? 

  • Work with your patient to make sure they have completed all appropriate screening tests this calendar year. This includes an HbA1c test, blood pressure screening, monitoring for nephropathy, and an eye exam. Sign off on their forms so that they qualify for two gift cards.
  • Consider recommending home glucose monitoring for your patient if they are not currently testing.
  • Review clinical practice guidelines to improve assessment and treatment of diabetes.

How do I make a referral to the asthma program? 

To refer a new patient or confirm a patient’s status in the program:

  • Call 1(415) 615-5198

How do I make a referral to the diabetes care program? 

To refer a new patient or confirm a patient’s status in the program:

  • Call 1(415) 615-5198

And at least one of the following criteria:

  • Diagnosis of asthma (two or more outpatient visits with asthma as primary diagnosis).
  • At least one systemic steroid with asthma as primary diagnosis and at least 1 bronchodilator and/or one controller prescription.
  • Two or three only rescue medications or short acting bronchodilator and at least one systemic steroid prescription with asthma as primary diagnosis.

And at least one of the following criteria:

  • At least two outpatient visits, ED visits or non-acute inpatient encounters, on different dates of service, with a diagnosis of diabetes. Visit type need not be the same for the two visits.
  • At least one acute inpatient encounter with a diagnosis of diabetes.
  • At least one insulin or hypoglycemics/antihyperglycemics prescription on an ambulatory basis.