Disease Management
The Disease Management (DM) Project began as a two year collaborative initiative in November 2010 among the Missouri Department of Behavioral Health (DBH), MO HealthNet Division (MHD), the Coalition of Community Mental Health Centers, and contracted DBH Providers. The project targets high cost Medicaid recipients who have severe mental illness and chronic medical conditions. The DM project has saved the Missouri Medicaid program millions of dollars, and more significantly, improved the health and well-being of thousands of people in Missouri.

As a result of the success of the program, disease management was expanded in 2014 to individuals with high medical costs, chronic medical conditions and substance use disorders. Many individuals with substance use disorders have other chronic diseases, yet behavioral and physical health services have historically been delivered through separate systems with little cross-system coordination. The expanded DM program seeks to effectively and efficiently coordinate care management to reduce costs and improve health outcomes.

During FY 2015, FCC was able to staff a multi-disciplinary DM Team. The FCC DM Team consists of a full time Clinical Manager as well as four full-time outreach care coordinators. The DM team provides outreach and engagement, coordinates necessary services with an emphasis on community support/case management to coordinate and manage their medical and psychiatric conditions. The FCC DM Program currently has 336 people actively enrolled in services. Additionally, 295 people are being outreached for potential enrollment. The FCC DM Team provides services in the following counties: Dunklin, Pemiscot, Butler, Wayne, Howell, Wright, Reynolds, Stoddard, New Madrid, Ripley, Carter, Scott, Mississippi, Oregon and Shannon.
DMH ADA DM Website

Disease Management 3700
The Disease Management 3700 Project (DM 3700) is a collaborative project between the Department of Mental Health and MO Health Net. The project targets high cost Medicaid clients who have impactable chronic medical conditions. Implementation for the project began as of November 1, 2010.
The Department of Mental Health has agreed to contact these identified persons, provide outreach and engagement, enroll them in the Community Psychiatric Rehabilitation (CPR) program, and provide necessary services, focusing on community support/case management to coordinate and manage their medical/psychiatric conditions. We believe our services and interventions will reduce the cost to the state of providing care and treatment and improve outcomes for the identified clients. While the outreach and initial enrollment will be through the Division of Behavioral Health (DBH), formerly the Divisions of Alcohol and Drug Abuse and Comprehensive Psychiatric Services, and the CPR program, if the client indicates a substance abuse disorder, they may be referred to the Division of Alcohol and Drug Abuse-CSTAR programs as appropriate.
DMH DM 3700 Website
What is the purpose of the ADA Disease Management Project?
  • Many individuals with substance use disorders have other chronic medical conditions (lung and liver disease, hepatitis, HIV/AIDS, heart disease, cancer, high blood pressure, diabetes). Often, some of these conditions go undetected or untreated resulting in fragmented care, poor outcomes, and high costs to the health care system.
  • The ADA DM project targets Medicaid-eligible adults with high medical costs and a history of substance use disorders. These individuals will also be likely to have other chronic health conditions. 
  • DMH contracted behavioral health providers engage in outreach activities to locate and enroll identified individuals in CSTAR or other appropriate DMH services (CPR/HCH if eligible). Once enrolled, services are coordinated with primary care and other providers to improve consumer outcomes and save Medicaid costs for the state of Missouri. 
Individuals in the DM cohort who are currently residing in another state, in a nursing home, or in jail are ineligible for the project until their
living situation changes or they are released from jail. These living situations make them ineligible to receive CPR or CSTAR services. Individuals residing in another state are ineligible for the project until they return to Missouri. CMHCs and CSTAR providers should check back with these individuals on a periodic basis to reevaluate their living situation.

Individuals in the DM cohort who are found to be deceased should be reported to DMH for formal exclusion from the project. Individuals who
are receiving hospice services or palliative care, who are on dialysis, or who have other questionable conditions should also be reported to
DMH on a case-by-case basis for review and possible exclusion from the project. 
Medicaid Eligibility
The DM project targets active MO HealthNet recipients who have a mental health or substance use diagnosis and high-risk
healthcare needs indicated in their Medicaid claims data. The purpose of the DM project is to provide care coordination and
manage overall healthcare more effectively to improve patient health and reduce overall costs to the Missouri Medicaid program
Success Stories
DK met with our DM Outreach CSS throughout the month of March and was admitted into CSTAR in April 2014. When our CSS first met DK and was invited into her home, she could not believe her eyes. DK was living in deplorable conditions with dilapidated surroundings, little food, little furniture, and exposed wiring. DK made it clear that she did not want to move. Our CSS continued to visit DK, sometimes sitting on crates outside of her house. Through continued rapport-building, our CSS discovered that DK has family not too far away. As the relationship continues to grow, DK is willing to entertain alternate housing options that would put her closer to her family. While DK hasn’t moved yet, she has been admitted into CSTAR and willing to discuss options. Our CSS is assisting with teaching her how to apply life skills in her current home environment to improve living conditions as much as possible until DK decides that she is ready to move.
DMH Success Stories
Clinical Manager
Ashley Singleton