KimSu Marder, RN, CCM

Lead Care Manager

KimSu Marder joined Health Catalyst in September 2015 as Care Manager Lead. Prior to coming to Health Catalyst, she worked for Tufts Health Plan as Care Management Relationship Manager. KimSu has a degree in Education from Lesley University, a degree in Nursing from Regis College, and is currently working on a Psychiatric Nurse Practitioner MSN at Regis College.

See content from KimSu Marder, RN, CCM

Improving Transitional Care Management – A Five-Step Framework

Research indicates that one in five readmissions could have been avoided with proper transitional care management (TCM). Given that Medicare readmission costs amount to $2.6 billion each year, decreasing readmissions through transitional care management is a priority for healthcare organizations. This article details a five-step framework that healthcare organizations can follow to set up successful TCM programs.

The framework emphasizes early, proactive care management that integrates hospital efforts with long-term care needs, home care, and other community resources. Once discharge occurs, it’s often too late to put care transition measures in place, resulting in higher readmission rates and higher healthcare costs.

Six Need-to-Know Guidelines for Successful Care Management

In a job that changes every minute, care managers don’t have much time to think as they tackle unpredictable situations. Care managers stay on track amid the distractions by following six key elements of successful care management:

1. Act as an advocate for the patient.
2. Practice cultural competence.
3. Garner support from leaders.
4.Develop effective communication skills.
5. Prioritize patients based on up-to-date data.
6. Don’t ever forget that the patient is a human being first.

As care managers practice these six crucial components for successful care management, the patient’s health and well-being will always be the top priority for everyone involved, which translates to better outcomes and lower costs.

Identifying Vulnerable Patients and Why They Matter

The vulnerable individuals in a health system’s patient population are at risk of becoming some of the organization’s most complex and costly members. Because vulnerability can be determined by long-term health status and social determinants of health (versus acute episodes), managing risk for these patients relies on a whole-person approach to care. Fee-for-service reimbursement hasn’t incentivized this comprehensive approach to care, but, under value-based payment models, health systems are increasingly rewarded for care that keeps patients well.

The first challenge in addressing the needs of vulnerable patients is identifying those patients. Analytics-driven technologies can help health systems understand who is vulnerable in their populations and take actions to control risk for these patients.

Care Management Analytics: Six Ways Data Drives Program Success

To succeed in improving outcomes and lowering costs, care management leaders must begin by selecting the patients most likely to benefit from their programs. To identify the right high-risk and rising-risk patients, care managers need data from across the continuum of care and tools to help them access that knowledge when they need it.

Analytics-driven technology helps care managers identify patients for their programs and manage their care to improve outcomes and lower costs in six key ways:

1. Identifies rising-risk patients.
2. Uses a specific social determinant assessment to capture factors beyond claims data.
3. Integrates EMR data to achieve quality measures.
4. Identifies patients for palliative or hospice care.
5. Identifies patients with chronic conditions.
6. Increases patient engagement.

10 Motivational Interviewing Strategies for Deeper Patient Engagement in Care Management

Care management programs are most successful when patients are deeply engaged in their own care. Using the motivational interviewing technique, care managers work with patients to identify personal care goals and motivators to follow the care management program.

Ten strategies guide the motivational interviewing process, each focusing on patient-centered insights (e.g., pros and cons to following care management and barriers to adherence). With mobile technology to support these interactions, motivational interviewing can become a seamless, and vital, part of the care management workflow.

Saving Lives: Effective Healthcare Communication Empowers Care Management

With an estimated 80 percent of medical errors resulting from miscommunication among healthcare teams, organizations can significantly improve outcomes with better communication. A communication methodology outlines the essential information clinicians need to share, giving care teams the knowledge they need, when they need it, to make informed treatment decisions.

One communication toolkit, SBAR (Situation, Background, Assessment, Recommendation), defines the essential information clinicians must share when they hand off patient care from the inpatient to the ambulatory setting:

1. S (situation): The patient’s current situation.
2. B (background): Information about the current situation.
3. A (assessment): Assessment of the situation and background and potential treatment options.
4. R (recommendation): Recommended action.

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