Although now recognized as a fundamental component of any
population health program, the concept of care management – care coordination, interventions and education for our most vulnerable patient populations – is a new one for providers. Historically, care management has been the provision of payers, and was most often handled through large call centers that made infrequent patient .
With the transition to value-based care, the responsibility for care management increasingly lies with providers. Many providers are inexperienced at care coordination across care settings, and they often lack the knowledge to stratify their patient populations. Provider networks with risk-bearing contracts are now utilizing care managers (called everything from case managers, to care coordinators, to clinical care managers) to help optimize their cost, utilization and quality outcomes.
After patients are identified as a likely fit for a targeted care management program, what then? How can providers institute a care management system that supports their care managers and helps them handle a heavy workload?
The problem with home-grown care management systems
Many facilities just beginning to dabble in care management are tracking their programs with documents and spreadsheets, entering a list of questions and answers, appointment dates and other static data. Care managers scramble to create their own clinical content repository based on their own research, but this content is usually focused on a single disease state and rarely maintained.
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Other organizations are attempting to manage high-risk patients within their EMR system, through customized forms or templates. While this approach does have the advantage of providing clinical data on each patient, EMRs are not designed for care management purposes. These systems lack automated workflows that alert the care manager to follow-up on critical work items to support the patient.
Without the most current clinical content, real-time analytics, daily workflow tools, or clinical alerts, these systems are just scratching the surface of care management – and they have little chance of improving patient care. For effective care management, you need a scalable, automated solution that provides a holistic view of the patient, along with the workflow tools that will help your care managers affect true change.
Support your care managers with evidence-based clinical content
An automated care management solution will provide your care managers with an evidence-based clinical assessment and integrated care plan for every patient they manage. The solution should use analytics-informed clinical content to generate a blended care plan, which incorporates prioritized goals for all of the patient's co-morbid conditions. The blended care plan allows the care manager to treat the patient holistically, instead of managing multiple, sometimes contradictory task lists for individual conditions. Most importantly, the plan should incorporate evidence-based clinical content that is extensively reviewed by a team of physicians – not out-of-date research performed by one overworked care manager.
The clinical assessment and care plan should be pre-populated with relevant clinical, lab and medication data, which saves the care manager time and ensures that no significant results are omitted. The automated solution should contain workflow tools that proactively alert care managers to abnormal lab results, hospital discharge data and other rich clinical information. Without alerts, the care manager cannot possibly sift through dozens of patients in order to track down which tests have or haven't been administered by various providers in various settings. A non-automated process is simply not going to provide timely access to critical clinical data.
Daily workflow tools to help your care managers affect patient behavior
In order to establish patient-centric goals, the care manager must have a complete picture of the patient's needs. The care management solution should guide the care manager through a conversational patient interview, providing actionable, condition-specific questions and capturing social determinants. By listening carefully to the answers, the care manager will better assess the patient's gaps in care, as well as understand the patient's personal health goals and both perceived and actual barriers to care.
Working in partnership with the patient, the care manager can establish a prioritized list of goals that the patient is eager to accomplish. A good care management system will provide evidence-based interventions and educational components that support the patient through the goal achievement process. The care manager can then activate a secondary goal, repeating this process as necessary. The result is a dynamic, continuous care plan that supports the patient's optimal health – and motivates rather than overwhelms.
Care managers need a solution that provides a comprehensive work queue to help them manage their day. A productive work queue should include prioritized work items, due/overdue reminders and prompts to complete tasks. Care managers should have the ability to set the frequency of follow-up required for a particular patient, and be able to edit workflow rules for a specific population.
An automated care management workflow and documentation solution will help you focus on the patients who can benefit most from your interventions – and it will provide your care managers with the tools they need to affect patient behavior and optimize outcomes.
To learn more about Studiomaca Care Manager™, our provider-oriented care management workflow and documentation solution, download our white paper, .