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How Your Healthcare System Can Improve Outcomes With Care Management

Healthcare systems, hospitals, clinics, and managed care organizations throughout the U.S. are striving to improve patient care and the well-being of patient populations while they control costs. The most effective way to improve managed care services for high-risk patient populations with chronic conditions is to implement Care Management.

What is Care Management?

Care Management is the team-based, patient-centered coordination of patient care and chronic conditions. By integrating various preventive care support systems more efficiently, Care Management programs reduce the need for medical services and improve outcomes for managed care organizations.

By promoting patient engagement and self-management, these innovative programs eliminate duplication and streamline care coordination for care managers and care teams across specialties.

Electronic medical records (EMRs) cannot accomplish the kind of care coordination required to meet the needs of today’s proven value-based care model. A robust Care Management program integrates data from all sources, stratifies patient risk, organizes patient intake, and manages care coordination for patients and care managers — all while measuring care team performance.

The technology required to support effective care coordination goes far beyond the mere digitization of a patient’s medical history. While EMRs are necessary sources for collecting and storing data, they are not the interactive workflow tool that care teams need for timely, judicious decision-making to minimize readmissions.

What is managed care?

Managed care is a healthcare delivery system that leverages established healthcare provider networks to enhance the quality of care and control costs of healthcare services. To become a member of a managed care network, providers must meet quality standards and pricing limits.

Types of managed care

The most common types of managed care organizations include:

  • Health maintenance organizations (HMOs)

Allow enrollees to choose their in-network primary care provider, who then makes referrals to specialized healthcare providers. This least-expensive insurance organization typically pays only in-network providers.

  • Preferred provider organizations (PPOs)

Allow enrollees to choose from a list of in-network primary care providers and specialty healthcare providers. Enrollees who choose out-of-network providers incur a higher cost but can typically see in-network specialty healthcare providers without a referral. This flexibility makes the PPO a more expensive health plan.

  • Point of service (POS) organizations

A cross between HMO and PPOs, POS managed care organizations allow enrollees to see in-network specialists without referrals. The cost of this health plan typically falls somewhere between HMO and PPOs.

  • Exclusive provider organizations (EPO)

Allow enrollees to choose in-network healthcare providers without having to establish a primary care provider or waiting for referrals. EPO managed care organizations do not cover all out-of-network healthcare costs.

Managed care plan enrollees also enjoy other financial incentives, including tiered copays for prescription drugs. Other high enrollment managed care health plans include Medicare and Medicaid managed care.

Medicare enrollees can see any healthcare provider at any managed healthcare organization that accepts Medicare. The Medicare Advantage managed care organization offers managed care plans with fixed networks of healthcare providers and managed care organizations for its enrollees.

Leading the way for insurance companies, the Affordable Care Act increased federal spending on Care Management for Medicaid enrollees with chronic conditions. Once the preventive care benefits were demonstrated, more provider networks began implementing Care Management to improve the delivery of healthcare and control costs in managed care organizations across the country.

How managed care organizations benefit from Care Management

Managed care organizations (or health maintenance organizations) have shaped healthcare delivery systems by creating preventative care strategies, treatment guidelines, and financial incentives.

To control costs, managed care organizations prioritize health insurance for preventive care. Payors do utilization reviews, evaluating the need and appropriateness of care on a patient-by-patient basis before it’s delivered. Physician checkups and age-based screening for various conditions identify potential dysfunctions early — before treatment and prescription drug costs build up.

Enrollees of managed care plans choose those insurers that contract with healthcare providers and work together to reduce healthcare costs. The main purpose of a managed care plan is to better serve plan members by focusing on prevention and care management, which help promote preventive care to produce better outcomes. Managed care helps healthcare providers, insurers, and patients cut costs.

Care Management enables those objectives and improves the quality of care by optimizing:

  • Case management
  • Utilization review
  • Care navigation

Managed care organizations that adopt these measures often control costs by improving outcomes and quality of care. That’s why more healthcare providers and managed care organizations are investing in, implementing, and reaping the benefits of Care Management programs every day.

How to implement Care Management

In order to implement successful Care Management, Health Catalyst recommends that care managers refine these five core competencies:

1. Stratify your patient intake.

Identify high-risk, high-utilization patients with chronic conditions by leveraging analytical tools that help care managers prioritize interventions in primary care clinics, emergency rooms, and specialist practices.

2. Integrate your data.

Successful care coordination requires the ability to pull data from multiple EMRs and other data sources — then aggregate it, analyze it, and make it available to the right team members at the right time.

3. Coordinate your care.

Prevent communication breakdowns by sharing patient assessments, care planning, and interventions with all care team members in a timely manner.

4. Engage your patients.

Inform patients about their care planning and facilitate both their self-management as well as care team communication through application-based secure messaging, assessments, care planning, and education.

5. Measure your performance.

Advanced reporting capabilities to show how the care team performed after analyzing and acting on the data provided.

The benefits of Care Management

Care Management is used to understand a patient’s health conditions and desired outcomes in order to teach them how to self-manage their symptoms. Armed with this knowledge, care managers can help patients realize many health benefits.

Here are some of the benefits you could see for patients after implementing a management program to improve the care delivered at your healthcare organization.

Improved quality of care

With Care Management, patients attend preventative and primary care visits more frequently thanks to provider intervention. The right program will enable a strong relationship between providers and patients, encouraging more frequent touchpoints and communication.

Providers can help their patients achieve improved health outcomes over the long term by closely monitoring their health. Gradual, positive changes to the patient’s habits and health will result in increased longevity and provide a better overall quality of life. While the results may not be immediate, healthcare organizations with Care Management programs consistently see improved clinical outcomes over time.

Increased patient satisfaction

When they feel they are truly being taken care of, patients perceive that they are receiving a higher quality of care. And when patients sincerely believe they can trust their care team to monitor their health, patient satisfaction may also increase.

It is a care manager’s job to understand each patient’s health history and any external factors that may be impacting their health — for better or worse. To gain this valuable information, care managers must build a trusting relationship with their patients and practice exceptional patient communication skills. When a patient feels their clinician is genuinely listening to their concerns, they will feel more satisfied in the patient-provider relationship.

Reduced indirect costs

While cost reductions are not often seen directly (nor right away) with Care Management programs, many indirect costs can be attributed to adding care managers to a care team. To see both clinical and financial success, healthcare organizations must carefully consider which patients would benefit the most from working with a care manager.

For example, management programs that target patients’ transitions from hospital to home see reduced hospital readmissions. These care programs ultimately lead to lowered costs, as readmissions increase operational costs for healthcare facilities.

Care Management programs can also reduce the use of high-cost acute care services, as well as the number of duplicative tests and procedures that often occur when a patient sees many care teams with different specialties.

Increased patient reach

An effective Care Management program can help your healthcare organization reduce administrative tasks and streamline care. Not only can you increase meaningful patient engagements, but you also free up time to support an increased number of patients overall. With all of this extra time, you can more easily scale your organization and increase your patient reach exponentially.

What’s the difference between Care Management and case management?

The terms “Care Management” and “case management” are mistakenly used interchangeably, but there are some key differences between the two.

Care Management

Care managers ensure patients are getting holistic, patient-centered care for all aspects of their health. A care manager’s job is to fully understand the underlying dynamics of their patient’s health, including social aspects — such as their relationships with family members and friends. Through this deep understanding of their patient, care managers can advocate for patient care that brings optimal treatments from providers and maximum benefits from insurers.

Case management

Case managers are often employed by agencies or insurers — such as Medicaid and Medicare — which means they are also focused on cutting healthcare costs.

Typically, case managers help patients navigate a specific disease, chronic condition, or circumstance. Their employer defines their scope of work and requires them to evaluate the financial effect of patient care on stakeholders, such as insurers. A big part of a case manager’s job is to eliminate noncompliance and overutilization. In other words, their job is to make sure the patient is getting what they need.

What makes a Care Management program successful?

To ensure that your Care Management program is successful and cost-effective, implement these key elements:

  • Patient engagement: Engaging not only patients but their families and support systems is vital to the success of your Care Management program. Patients should feel like an integral part of the care team and have a say in decision-making. Patients who engage in self-management are more likely to see improved clinical outcomes.
  • Training: Care managers should be properly trained to provide holistic, patient-centered care. This includes learning valuable skills that will help patients achieve improved health outcomes, which require efficient patient-provider communication and care coordination.
  • Support system: Patients with chronic conditions, particularly those that entail mental health challenges, require strong support from both care teams and loved ones.

How does Care Management improve outcomes?

While Care Management can be helpful in many clinical settings, it is essential to manage and monitor patients with mental and behavioral health conditions — holistic health services are critical to their well-being and improve quality of care.

With mental healthcare management, clinicians can ensure that patients’ physical, mental, emotional, and social needs are met so they are able to lead full lives. Healthcare organizations can analyze patient populations and their unique mental health needs to determine what type of support is required.

The same principles can be applied to behavioral health conditions like drug addiction — a multifaceted behavioral health condition that requires whole-person care management. Patients with comorbidities generally have a higher risk of chronic conditions like depression and anxiety. Care Management programs allow care teams to address all symptoms — not just the physical ones.

Care Management strategies

The main purpose of Care Management is to identify and provide healthcare for high-risk patients who often have socioeconomic-based comorbidities. This innovation has helped managed care organizations control costs for public health initiatives.

Traditionally, healthcare professionals fell into two categories: specialists focused on single clinical conditions and primary care providers with a very general understanding of multiple high-risk chronic conditions. Care Management programs allow them to integrate their services for superior patient care.

The Agency for Healthcare Research and Quality recommends that primary care providers, care managers, provider networks, healthcare systems administrators, payors, Medicare and Medicaid, as well as other public health officials and policymakers follow these managed care strategies:

1. Identify populations with modifiable risks.

Use relevant metrics and patient-generated data to identify patients with high-risk chronic conditions who are most in need of Care Management and improve managed healthcare.

2. Adjust Care Management to patient needs.

Gather and analyze input from patients on primary care and acute care of health conditions with modifiable risks. Then, choose a Care Management program that improves the quality of care for chronic condition management through automated care planning and streamlined communication.

3. Identify and train personnel.

Determine which skills, training, and licensure requirements managed care team members must complete in order to implement the most effective Care Management program. Develop models for interprofessional education to ensure care coordination promotes well-being for all.

4. Choose an all-inclusive Care Management program.

A successful Care Management system will not be bound by a single EMR — it will span a variety of data sources that enable cross-specialty care team communication. Patients, acute care, primary care, and specialty care providers — as well as therapists, social workers, and care managers — should all be able to communicate transparently. Only then will healthcare providers, hospitals, health plans, and other healthcare constituents be able to deliver the kind of care coordination required to achieve better outcomes for high-risk patient populations.

5. Choose a Care Management program with analytics at its core.

A Care Management program that was built to support the patient-provider relationship has analytics in its DNA. It analyzes data, trends, and patterns to drive better patient care.

It automates clinical healthcare processes, suggests efficient workflows, identifies and stratifies high-risk patients, and enables better decision-making and quality of care for chronic conditions. It enables your care management team to access your personas, targets, MQLs, and SQLs, as well as patients and future patients who need wellness-promoting education.

What is Care Management software?

Value-based care reimbursement models are replacing outdated traditional healthcare delivery. With the shift to patient-centered, holistic care well underway, managed care organizations need to rethink their delivery of health care.

A Care Management program that was designed to support the value-based reimbursement model brings primary care providers and diverse specialty care teams one step closer to seamless, whole-person case management and improved quality of care.

From streamlining patient-provider communication and engaging patients to addressing the social determinants of health to providing touchpoints in between appointments, a robust Care Management program will help your managed care team improve satisfaction for both patients and providers while restructuring reimbursement to control costs and bolster your bottom line.

Care Management programs are, at their core, patient-centric, so implementing one is a great step toward improving the patient experience and quality of care during chronic disease management to streamline coordination of care and control costs.

Learn how improving the quality of care increases the well-being of your care team as well. Download our e-book, How to Create Amazing Patient Experiences.