Care Management Solutions

By | April 28, 2017

Care Management Solutions

Defining Care Management Solution

Care Management solution is the art and science of monitoring and maintaining a person’s health between hospital or physician interactions. It involves encouraging right actions by or on behalf of the person, at the right time, and identifying the need of appropriate interventions. A well-executed care management program can go a long way in achieving the triple aim of: improved outcome, lower cost, and increased (patient) satisfaction.

Care Management 1.0 – how is it done today?

Care Management in the healthcare industry has traditionally been driven by Health Plans, who have had the economic interest in reducing the cost of care. The delivery has been led by Care Managers, who are nurses or other healthcare workers, relying primarily on telephonic interaction with individuals receiving the care. These Care Managers have relied on the claims data or self-reported data by members, which has the perils of some combination of being delayed, incomplete and inaccurate. Reliance on telephonic interaction also poses the problem of reaching a member at a time suitable for and preferred by him or her. As a consequence, care managers typically spend more time chasing a member than enabling management of care for them. In the midst of all of these problems, providers have remained only loosely connected with care management programs due to very distinct non-overlapping distribution of responsibilities between Health Plans and Providers.

Care managers typically spend more time chasing
a member than enabling management of care

As a result most care management programs suffer low participation and poor compliance. No wonder, traditional care management programs have not been able to deliver the promised value despite the best efforts by care managers and Health Plans.

Care Management Solution 2.0 – how is it evolving?

With the emergence of new payment models including but not limited to bundled payments and ACOs, the industry is decidedly shifting from fee-for-service to value-based healthcare reimbursement. This has catalyzed significant changes in the need for care management, which is now emerging as a priority for Providers along with Health Plans.

With Providers taking on more risk-share payment arrangements, there is a greater incentive for them to work with Health Plans to implement effective care management strategies. Hence there is an increased willingness by Providers to invest in care management programs. At the same time, Health Plans are increasingly exploring ways to work with Providers to synchronize care management activities.

Simultaneously, technological innovation and resulting penetration of mobile devices have led to vast new opportunities to reach members, which didn’t exist even a few years ago. This opens up exciting new avenues of synchronous and asynchronous communication that can be personalized down to the population of one.

Synchronous and asynchronous communication
that can be personalized down to the population of one.

The combination of these two factors has a transformative impact on the discipline of care management as we know it. While this potential transformation does not change the fundamental strategies or invalidate decades of learning of the discipline, it does present new opportunities to implement, and sometimes modify, them.

Coordination of the care Management team

With providers launching their own care management initiatives, the industry is at a crossroads – what is the right structure and ownership of care management programs?

Multiple entities running care management programs has the potential of creating confusion and irritation for members who are the target beneficiaries. Instead of increasing participation and compliance such overlap and confusion may make it even worse.

An integrated continuum of care will deliver a single Care Plan to members, and will be driven by a single “quarterback” managing that delivery with the rest of the care team blocking, tackling or catching based on their roles.

Successful approaches in care management will see increasing coordination between Health Plans and Providers. An integrated continuum of care will deliver a single Care Plan to members and will be driven by a single “quarterback” managing that delivery with the rest of the care team blocking, tackling or catching based on their roles.

The same continuum will also hold over for the life of a member, as a member transitions from one care setting to another, and one type of care need to another. Moving from post-acute to long-term chronic care, for instance, will not mean handoff across organizations and programs, but will mean the evolution of care plan with morphing roles of stakeholders and frequency of touch.

Who needs care management programs?

While the industry is still in great flux, it is becoming clear that an increasingly varied type of entities needs care management, and opportunities are emerging for greater alignment. Various industry participants that need to think about (or rethink) their care management strategy:

1. Hospitals and multi-practice physician organizations

These organizations are taking on risk for some of their patients in the form of bundled payments or other risk share arrangements. They are also under a constant threat of penalties resulting from avoidable readmissions and often spend a lot of effort and money on preventing that penalty. They usually have a limited care coordination program in place that helps synchronize healthcare resources and schedule followup appointments. However, to accomplish their goals, they need a full blown care management program which requires operational as well as technological enhancements. While they would do best by coordinating their care management initiatives with Health Plans, they typically work with multiple Plans, complicating the ability to coordinate. They need their technology to be integrated with EMRs. Solution provided by most EMRs vendors are inadequate for various reasons, complicating their technology decisions.They do not have the benefit of much experience in managing care post-transition out of their facilities, and would need to integrate the care management efforts with any existing outpatient chronic disease management programs, and outpatient clinics.

2. Long term care facilities

Long term facilities are downstream participants of bundled payment arrangements adopted by hospitals. They do not have the budget to roll out an independent program and will be best served by coordinating their care management initiatives with those of hospitals’.

3. Accountable Care Organizations

These organizations are integrated systems taking on risk for their members in the form of risk share, gain share or full capitation arrangements. They have a health plan as a part of the organization and hence have established care management capabilities. Their capabilities, however, suffer the shortcomings of traditional Health Plan based care management programs. They can enhance these programs by promoting greater coordination between participating providers and using recent member engagement approaches. They need enhanced workflows and technology to accomplish their care management goals.

4. Health plans with increased exchange population

Health Plans participating in Health Insurance Exchanges are facing increasing commercial population that are all at risk. With the increase in risk pool, the need for effective care management is higher than ever before. They need to increase the effectiveness of their care management programs to manage the new risk, which means driving higher member engagement and compliance than their current programs are able to achieve. They have a very capable staff in place and have a significant investment in technology. They need to enhance their capability by complimenting their existing operational and technology infrastructure, not replacing it. Given the need to evolve a sizable existing care management programs, it is a difficult organizational change management problem, which is best spearheaded by bold and creative leadership at all levels of their organization.

5. Medicaid plans with increasing enrollment

Most Medicaid plans have seen increased enrollment. They have also seen an increase in coordination attempts like Patient Centered Medical Homes (PCMHs). While they would like to delegate care management initiatives to PCMHs, the distributed scale and lack of expertise makes such an approach unrealistic. Hence, the larger pool, and newer initiatives, necessitate increase in scope and function of their care management programs. Their task is even more challenging than that of Health Plans in that in involves significant expansion, change management, and oftentimes a severe financial limitation. Addition of MCOs by many states adds another dimension to their task of implementing an efficient and effective care management program.

6. Medicare plans with the highest risk population

Medicare plans have the highest risk population. They have typically run extensive care management programs, which include complex case management, case management and disease management. With new payment arrangements and new technology, they need to enhance their care management capabilities by modernizing their technology and workflows. Additionally, they need a more coordinated care management approach with providers. They also need the new technology to work along with their existing technology. They also face a daunting organizational change management challenge.

7. Employers facing higher medical costs

Self-insured employers are facing increasing medical cost, and are passing more of it to employees. Selective care management approaches can help them control the cost while offering better healthcare options to their employees. They are already providing incentives for change in health behavior. Layering a targeted care management program can make those initiatives more effective.

Challenges faced by Care Management solution 1.0

While each of the above organizations face their own unique challenges, a few obstacles are common across all of them. Adaptation of a program that fundamentally solves these obstacles is likely the most effective approach for them.

Common obstacles:

1. Inability to reach members/patients

Primary means for care managers to get in touch with members is through telephonic conversation, during work hours. The resource intensive nature of this approach forces only a small percentage (2-5%) of population to be included in any care management program. Even that population is contacted based on a pre-determined schedule, often not any more frequently than once a month. Furthermore, those infrequent contacts are rarely at the convenience of the member, and often need multiple attempts to even have a conversation. The result is unenthusiastic participation by members, leading to poor compliance.

2. Delayed information

The information based on which care managers operate comes from claims. That information is delayed and incomplete (for instance, it says that a test was done, but not what the result of the test was). Lacking current information, care managers have limited ability to recommend timely interventions stunting the value of the care management program.

3. One size fits all approach

Care managers hardly have any systemic ability to personalize their approach for each member. Current programs depend on care managers’ personal ability and initiative to connect with members, which obviously is uncertain and uneven. Lack of personal connection is another disincentive for members to value the program.

On to Care Management solution 2.0

In light of the challenges facing Care Management 1.0, a program that allows multi-channel, asynchronous, on demand communication with members can solve a big hurdle in interacting with them. Additionally, personalization of interaction with members can further enhance their willingness to actively participate. Finally, insight into the everyday condition of a member can empower care managers to prompt timely interventions, which may prevent the escalation of a problem while increasing members’ confidence and engagement in the program.

Note the emphasis on minimizing member efforts,
empowering care managers, and simplifying for all stakeholders.

While several approaches attempt to address these problems using mobile apps for members, over reliance on such apps puts a significant amount of demand on members and does little to empower care managers, who are a critical part of any care management program. The optimal approach to a modern care management program, therefore, is a mix of what has worked in the past (use of expert care managers providing a human touch and intelligence), approaches made possible by new payment models (alignment of provider and Health plan interests), and new technology (simpler and smarter technology offered to care managers supported by sleek biometric and mobile devices for members). This combination should create a sensible care team, empower the participating care managers, and enable members to plug in while asking for minimal effort on their part. Note the emphasis on minimizing member efforts, empowering care managers, and simplifying for all stakeholders.

KISS for Care Management Solution

The age old principle of “Keeping It Simple, Stupid” could not be more applicable while considering the implementation of Care Management 2.0. Simplification does not mean doing only simple things, but means prioritizing highly effective things, and making them intuitive and efficient. Striving for simplicity in an inherently complex endeavor, such as this, requires clarity of goals, expertise, and commitment. It also requires recognition that different approaches are needed for simplicity for members (non healthcare and technology experts) and that for care managers (health care experts).

For established care management programs, it starts with an across the organization “buy in” of the opportunity presented by this change. It involves inspiring and supporting the staff with easy to use, yet powerful, technology and workflows. It also includes recognition by the leadership to expect more from their care management program, and start measuring the success parameters that actually move the needle towards achieving the triple aim goals. The need for reporting for compliance complicates this effort and must be dealt with practically. For new care management programs, an appropriate emphasis on people, process and technology, coupled with an incremental roll out approach, can be most effective.

Can MEDSOLIS help?

MEDSOLIS suite of care management solution is designed from the ground up to address precisely the problems in the current approaches, and take advantage of new possibilities. Moreover, it does so without requiring any additional infrastructure investment, minimal training, and no additional human resources. Finally, it prioritizes adherence to the principle of simplification.

MEDSOLIS’ care management program How it works

MEDSOLIS proposes a care management program – mPower – that is a combination of suggested workflows and a suite of applications. Both the workflows and the technology are amenable to incremental customization allowing care managers to make it their program. The suite has the following components:

• mCompanion: A smartphone and tablet app for members that is capable of connecting wirelessly with a wide range biometric devices such as glucometer, BP monitor, oximeter, and weight scale.

• CareConnect: A web based interface for care managers that is a smart and simple to use care management application

• mDoc: An optional smart app for physicians, if their involvement is a part of the workflow

The MEDSOLIS application delivers a personalized care plan for members/patients, and helps them comply with it. It sends to them timely notifications and simple actions to be performed by them. As they execute those simple actions, the care plan compliance is automatically achieved without them having to bother about learning it, or even knowing about it.

During this interaction, the application captures information about member’s day-to-day progress and summarizes it in real-time on their care manager’s dashboard, where the platform dynamically prioritizes which members need attention at any given time. Using these insights, care managers can communicate directly with members via the product’s secure communication command center. Communication options include offline messages and / or questions, thereby reducing the need of burdensome live communication.

The impact of MEDSOLIS

MEDSOLIS does not replace human care. It simplifies and amplifies it. By drastically reducing the burden of unproductive activities, it makes care managers more efficient and effective. Further, it empowers care managers to operate closer to the top of their license, connecting with members in a more continuous and better informed manner. It enables personalized care planning, communi-cation and education for each member. This helps members feel better supported and cared for. Finally, it enhances the strategic and financial value of the existing care management program by optimizing utilization, increasing revenue through value-based payment, and improving network retention.

Implementing MEDSOLIS’ care management program

Adding MEDSOLIS to your care management program is easy, and getting started doesn’t require replacing current systems or additional IT investment. The MEDSOLIS platform integrates with existing systems and can be configured to meet the needs of diverse clinical programs. It can be personalized and adapted to members’ specific needs. It enables collaboration across a care team, and supports standard evidence based care guidelines. More importantly, it provides the necessary support to deliver the program goals beyond just offering the technology.


The bottom line

MEDSOLIS products are simple, effective and efficient. They can be implemented easily. They can substantially increase the return on your care management investment.

If you would like to explore how MEDSOLIS can help you, please ask for a demo! | | 7460 Warren Parkway, Suite 100, Frisco TX 75034

You may also like reading – There’s an App for that!