Care management encompasses all the coordination activities needed to help manage chronic diseases. It is a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively. The idea of care management is being able to efficiently manage a selected set of individuals to focus on reduced cost and better quality of care. This idea and practice have been around for a long time, primarily established in the payer space. However, with the growth of value-based incentives and risk-based contracting, healthcare provider organizations have started to think of more advanced Care Management Solutions, also called “complex care” and “disease management,” in the context of population health strategies.
When handled properly, Care management will reduce the cost and increase the quality of care for those individuals identified in the program. While Medicare data suggests that only 5 percent of a healthcare organization’s population consumes 50 percent of its resources, health systems must look beyond that 5 percent and also use a strategy that will allow them to identify and work with the people they will impact the most.
Care management solutions seek to provide answers to care management struggles. There are care management solutions suggested by organizations such as Health Catalyst have shown to be tested and true. To better illustrate Care management, picture this:
Just five percent of patients consume close to 50 percent of an average health system’s utilization and costs of care. This means effective population health management programs must have a strong care management focus in order to be effective. For a long time until recently, care management teams were forced to use a patchwork of products and fill the gaps with manual work. Teams were spread thin and challenged with an ever-increasing number of patients. But it shouldn’t be so. Care teams deserve a dynamic end-to-end solution that helps drive the work on improving care while lowering costs. This a solution that delivers the right care to the right patient at the right time. Introducing Care Management Software solutions developed in partnership with industry leaders has helped to shift focus to the five core competencies of care management: 1. Data Integration, 2. Patient Stratification and Intake, 3. Care Coordination, 4. Patient Engagement, and 5. Performance Measurement.
Data Integration: Data integration is a process that aggregates, analyzes, and delivers data to the right people at the right time. Gives care team members access to multiple EMRs and data sources spanning the entire care continuum, from hospitals to pharmacies.
Patient Stratification and Intake: Patient stratification uses an agile patient stratification process to integrate current utilizations and trends, chronic conditions, active medications, and social determinants from disparate clinical and claims data sources.
Care Coordination: Care coordination facilitates timely, all-inclusive care team communication and collaboration on patient assessments, care planning, and interventions.
Patient Engagement: Patient engagement is usually a mobile-first approach (smartphone apps) enables secure, real-time, multi-point messaging, assessments, and care planning to engage and support all care team members (patients, friends, families, social workers, care navigators, etc.) across multiple EMRs.
Performance Measurement: Performance measurement evaluates and reports on care management program effectiveness using metrics and measures appropriate to value-based contracting.
In order to manage resources sustainably, practices must accurately identify individuals and entire populations that can control risk factors, and by doing so improve their health. Careful management of select populations may increase the quality of care like improving the delivery of appropriate clinical preventive services. Consider, for example, a population of patients who have not yet developed one or more chronic diseases such as diabetes mellitus, but are at risk of doing so. The risk of progression from glucose intolerance to diabetes mellitus can be influenced by diet and exercise. Individuals within this “rising risk” population are at different stages of readiness to change, and consequently at different stages of modifiable risk. This insight allows providers to offer services at the appropriate level and time.