Our Signature Care Management Programs And Services

Complex Case Management/Case Management/Disease Management

• MDX Hawaii has partnered with Conifer Health Solutions to support patients who need additional support navigating the health system. There are 3 components to their program:
  • Transition Care Team – Members who have been discharged from the hospital will have a telephonic call upon discharge to ensure a smooth transition to home. During these calls, the nurse or coordinator can help members to ensure that any orders, i.e. DME, home health, meal delivery, etc., are received by the vendor.  They also ensure that a follow up visit back to the PCP or specialist is in place.  Usually, these touches are one to two times to check on members post discharge.  If further assistance is needed, they may refer the member to case management
  • Case Management/Complex Case Management – Members who require additional support can be referred by the member/caregiver, hospital, providers, MDX Hawaii, or by the health plan. In addition to referrals, members that have frequent hospitalizations or emergency room visits, have a new chronic diagnosis or need additional support for referrals or care will be called.  Based on the services needed and care plan, members requiring a care plan and additional follow up will be transferred to the complex case management program
  • Disease Management – The disease management program targets priority and high-priority members identified through risk stratification based on their chronic conditions, including COPD, coronary artery disease, congestive heart failure, diabetes, and chronic kidney disease/end-stage renal disease. These members receive proactive monthly outreach through phone calls and mailings to provide education, support, and resources aimed at improving health outcomes, enhancing disease management, and reducing hospitalizations.
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• Referrals can be sent via email: FrmCaseManagement@coniferhealth.com

Ala’O Ho’ola, Pathways to Healing

• MDX Hawaii has an internal program, Ala ‘O Ho’ola, aimed to support high-risk or rising-risk patients who may benefit from additional help with managing complex health conditions. Members with 2 or more chronic conditions that may not be improving, multiple readmissions with same diagnosis, multiple ER visits with same diagnosis, members that are home bound that cannot access their provider, members with polypharmacy that require medication review/management, or members needing additional education on pathophysiology of a new diagnosis.
• The patient works with a care management team that includes a Nurse Practitioner, Pharmacist, and Coordinator.
• Patients’ opt-in to the program and remain actively engaged for anywhere to a comprehensive assessment or annual wellness visit to up to 6 months depending on complexity of needs, care plan interventions and patient preference.
• The areas of focus are health education, helping complex patients understand their conditions, addressing pharmacy needs, identifying appropriate community resources, supporting advanced care planning/ life care planning, and assistance with obtaining PCP or specialists appointments.
• Referrals can be sent via email: AlaOHoolaNP@mdxhawaii.com

Palliative Care

• MDX Hawaii has partnered with Hospice programs on Oahu, Maui and Kauai to create this newly added palliative care benefit to provide the support needed to improve quality of life for patients with serious illnesses. Serious illnesses may include cancer, heart disease or heart failure, end-stage kidney or liver disease, chronic obstructive pulmonary disease, amyotrophic lateral sclerosis (ALS), and dementia. In addition, members with declining ability to complete ADLs, marked weight loss, difficulty controlling physical/emotional symptoms related to a serious medical illness or uncertainty of prognosis of care are other factors that this program can assist. 
• A palliative care algorithm generates a score for inclusion and together with the primary care provider, patients are validated for possible enrollment in the program.
• Palliative care services are covered by MDX for 90 days with the potential to be extended after clinical review.
• The patient has in-home support from a palliative team that includes a palliative medicine physician, nurse practitioner, registered nurse case manager, pharmacist, chaplain, and social worker.
• The patient’s goals for care guide the team and care plan to reduce harm, increase quality of life, manage pain and symptoms and transition to hospice care when requested.
• Referrals can be emailed: AlaOHoolaNP@mdxhawaii.com

Integrated Health Hawaii (IHH) for Behavioral Health

Helping Medicare Advantage Members Stay Engaged in Their Care

• MDX Hawaii has partnered with Integrated Health Hawaii (IHH) to provide care coordination services for Medicare Advantage members who may be ready to address behavioral health concerns. IHH provides care coordination services for these members who may be experiencing stress, memory concerns, sleep difficulties, or challenges managing their health.  This support is designed to work in alignment with the care already being provided by the primary care physician.
• Members may benefit from this program if they:
  • Are experiencing stress, anxiety, or changes in mood
  • Show signs of memory loss or cognitive changes
  • Have sleep difficulties or rely on medications such as Ambien or anti-anxiety medications
  • Have had frequent hospital or emergency room visits related to behavioral or psychosocial needs
  • Are navigating caregiving responsibilities, life transitions, or feelings of isolation
• Services provided by IHH include: 
  • Collaborating with the physician, specialists, family, and care team 
  • Supporting appointment scheduling and medication access 

• • Coordinating transportation to medical visits and connecting members to translation services when needed 
  • Helping members access community and social support resources 
  • Guiding members in connecting with appropriate specialists, including behavioral health when appropriate 

• IHH provides whole-person care, supporting both physical and emotional health so that members feel confident and connected in managing their health needs.
• Referrals can be emailed: Info@integratedhealthhawaii.com

Malama Kidney Center (MKC) for Chronic Kidney Disease (CKD)

• MDX Hawaii has partnered with Mālama Kidney Center to serve as an extension of the Nephrologist and PCP’s practice by providing CKD education, support, and care coordination for member’s living with CKD.
• The care team consists of a nurse practitioner, registered dietician, social worker, care manager and behavioral health provider.
• Members eligible for the program are those with CKD stages 3 to 5. The team will work with the PCP and nephrologist and create an individualized care plan that helps members understand their condition and aims to slow its progression. The program also provides education on the importance of a healthy diet for individual living with CKD, offers meal planning tools, and offers health coaching to build healthy habits, as well as therapeutic counseling to help manage stress related to CKD.  Additionally, it provides information about available renal replacement therapy options.
• Referrals can be emailed: aloha@malamakidney.com

Kidney Care 365/Interwell Program for ESKD

• MDX Hawaii has partnered with Interwell to support patients who have been diagnosed with chronic kidney disease (CKD 4/5 along with end stage kidney disease ESKD) that are being seen at Liberty / Fresenius Dialysis Centers.
• The patient has access to a care team that includes a care coordinator, nurse, social worker, and renal dietician. Progress updates are routinely shared with the patient’s PCP, Nephrologist, and specialists or medical group’s centralized care management team if preferred.
• The Kidney Care 365 program areas of focus are early kidney health education, slowing the progression of chronic kidney disease, help patients make informed choices, and manage overall health and comorbidities.

Medication Adherence – Community Pharmacy Enhanced Services Network (CPESN)

• MDX Hawaii has partnered with CPESN, a network of independent local pharmacies (e.g. Times, Don Quijote Drugs, 5 Minute, etc.) to improve medication adherence and quality of care for our members at their local pharmacies.
• For members who fill prescriptions at these pharmacies, the pharmacists will ensure timely refill of chronic prescriptions and triage any medication related questions. This is a high touch program delivered through leveraging the relationship between patients and their local pharmacists to improve medication utilization through adherence programs.
• Referrals are directly from MDX Hawaii based on members obtaining chronic medications through these local pharmacies. For a list of participating pharmacies, please contact Wen@mdxhawaii.com.

Arine Medication Management Program

• MDX Hawaii has partnered with Arine, a leader in AI-driven medication optimization, to support providers in managing complex medication regimens for high-risk patients. Led by clinical pharmacists, this program ensures each patient receives safe, effective, and clinically appropriate medication regimen tailored to their unique healthcare needs.
• This program serves as an extension of the provider’s practice, offering expert guidance to support informed medication decisions. By combining clinical expertise with Arine’s advanced analytics, the program helps identify potential medication-related risks before they result in adverse outcomes—leading to improved patient health and reduced overall healthcare costs.
• Arine’s advanced AI models analyze broad datasets to identify and prioritize patients with the highest risk and greatest potential for impact from medication interventions. However, if there are patients that you feel would benefit from this program, please reach out to Wen@mdxhawaii.com.