Our Signature Care Management Programs and Services

Our experienced and highly trained care managers and nurses are available to assist MDX Hawai‘i patients and their families with managing their medical, psychological and practical issues created by illness, hospitalization or medical treatment.



We help patients and their family understand and manage chronic conditions such as chronic kidney disease, congestive heart failure (CHF) and diabetes. Our highly experienced and specially trained nurses work with patients and their caregivers to educate them about their condition, and to help develop a care plan. We strive to improve the health and wellness of members with these chronic conditions.


Our Ala ’o Hoola team consists of experienced Nurse Practitioners, Registered Nurses, and Care Coordinators who are here to assist patients in managing their health conditions or any additional support they may need. These programs are not designed to replace the care provided by physician but are available free of charge to help patients maintain or improve their health. 

MDX Hawai‘i’s Care Management Team collaborates with members, caregivers, families and providers to assist our members with complex needs by:

  • This referral-based program supports high-risk or rising-risk patients who could benefit from additional help to manage complex health conditions.  
  • The patient has access to a care management team that includes a registered nurse care manager, nurse practitioner, pharmacist, and care management coordinator. 
  • Patients are actively engaged for 2-6 months depending on complexity of needs and patient needs. 
  • Nurse care managers identify patient goals, barriers and provide health education to help patients understand their conditions and how to remain healthy at home.   
  • Pathways to Healing helps patients and their families develop a care plan that addresses all aspects of their care including end of life planning, which includes palliative care or transition to hospice. 

Patients may enroll in our programs directly, or a primary care doctor can refer patients.

We work closely with the patient’s physicians and keep them your informed of the patient’s participation and progress. For more information about the programs, please call (808) 532-6898 on O‘ahu or 1-800-851-7110 toll-free from the Neighbor Islands. 

You can enroll in our programs directly, or your doctor can refer you. The programs are fully covered benefits in your Medicare Advantage plan. There is no cost to you. They are designed to give our patients additional support, and do not take the place of the care provided by your physician. We will keep your physician informed of your participation and progress. For more information about the programs, please call (808) 532-6898 on O‘ahu or 1-800-851-7110 toll-free from the Neighbor Islands.


Palliative Care Program  

  • This new program was created to ensure critical support for patients with serious illnesses. Patients have in-home support from the palliative team that includes a palliative medicine physician, nurse practitioner, social worker, registered nurse case manager, pharmacist, and chaplain. 
  • MDX Hawai’i will cover the total cost of the program up to 90 -days with the potential for an extension - requires PCP request and medical review.  With agreement from PCP and patient/family, referrals are made to the preferred agency. 
  • The patients’ 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 appropriate 

    Kidney Care 365 
  • Patients who have been diagnosed with chronic kidney disease stage 4 (CKD) or with end stage kidney disease stage 5 (CKD 4/5 along with end stage kidney disease (ESKD) will have 24/7 access to a team that includes a renal dietician, social worker, care coordinator, nurse and pharmacist.  
  • Progress updates are routinely shared with the patient’s PCP, Nephrologist, and specialists and/or a medical group’s centralized care management team. 
  • Kidney Care 365 team helps patients understand important kidney health topics.  Adopting healthy habits  can dramatically slow the progression of chronic kidney disease. Patients are prepared to make informed choices to manage their health. 



We encourage patients to take an active part in staying healthy. If there are ongoing health issues or special needs, the patient should talk to their primary care physician about developing a plan to address them.


  • Annual wellness visit with a PCP or with one of MDX Hawaii Nurse Practitioner (NP) Programs
  • Blood pressure measurement at every visit
  • Flu vaccination
  • Pneumonia vaccination

In addition to routine care, patients should talk to their primary care physician about these important topics:

  • How to reduce the risk of falls
  • Frequency of colorectal cancer screening
  • Amount of physical activity needed to improve and maintain health
  • Anxiety, stress or depression 
  • Usage and side effects of prescription and over-the-counter medications


  • Mammogram for breast cancer screening every two years, or when recommended by a physician
  • Osteoporosis testing or DEXA Scan test after age 65 and/or after a fracture


  • Hemoglobin A1c blood test
  • Retinal eye exam (annually)
  • Foot exam
  • Kidney test


In many cases, generic medications are the same as brand-name drugs in dosage, quality, strength, and intended use and performance, and are available at a lower cost.


A primary care physician may not always be available when medical problems occur. Urgent Care centers can offer treatment for illnesses or minor injuries.

Examples include:

  • Fever or severe sore throat
  • Minor stomach pain
  • Minor wounds that require stitches
  • Minor injuries such as sprains or broken bones

Patients should always notify their primary care physician of any care received in an urgent care center.


In a life-threatening situation, or when dealing with serious injuries, immediately call 911 or go directly to the nearest emergency department.

Once there, patients should inform the emergency department staff of their primary care physician, so that their physician can help coordinate their care. If a patient is hospitalized, the patient or a family member should notify their primary care physician as soon as their condition is stabilized.


Post-discharge patients should make an appointment to see their primary care physician right after they are discharged. The patient's doctor and care team will go over their discharge instructions, medical conditions, test results, medications and follow-up plan and answer any questions patients or their family members may have. Be sure to bring all the medication you are taking at home during this follow up visit to make sure you should continue to take them along with any medication ordered at the hospital.