Six Need-to-Know Guidelines for Successful Care Management

Care managers wear many hats—from patient advocate to care-team collaborator, care-plan creator, and patient and family educator. With this dynamic, diverse job, there is no such thing as a “typical” day. Care management success is achieved when care managers are as agile as the ever-changing human beings they care for.

In a complex healthcare system, patients receive care from multiple providers, all of whom are considered specialists because they focus on delivering care in one key area. The care manager has the ultimate challenge—putting various aspects of care together to create a comprehensive vantage point with the patient at the center. To add to the intricacy of the job, care managers have to manage patients, as well as the unpredictability and constant change that comes with human nature.

Part of the unpredictability challenge is the stage of change the patient is in when the care manager contacts them. For example, although the patient may know they have to stop smoking to become healthier, they may not be ready to commit to a behavior change to make that happen. Care managers must assess the stage of readiness and then guide the patient through the process until they are ready to commit to improving their health.

Six Key Elements of Care Management Success

This article discusses six key elements that empower care managers to advocate for patients, avoid common pitfalls and roadblocks, and ultimately ensure the patient receives the best care—how, when, and where they need it. While a day in the life of a care manager can take many twists and turns, foundational guidelines help care managers achieve care management success and put the patient first, no matter what unexpected changes and circumstances arise.

1. Patient Advocacy

As patients seek care and services from primary care providers (PCPs), specialists, social workers, financial aid resources, food banks, etc., they may feel lost in the complex healthcare system. Patients may be unsure about what details of care are important, when to share them, and with whom. Often, the most confusing part for the patient is navigating today’s healthcare system—what procedures are covered, how to prioritize personal health goals, and which resources will help the patient achieve these personal health goals. The care manager’s job is to guide patients through the process and advocate for them along the way.

An example of patient advocacy could mean working with a patient who is nonverbal but would like a power chair for mobility (e.g., a patient who has lost the ability to walk but needs to retain some level of independence). Ordering and building a power chair involves many steps and requirements, and patients and families may not know where to start. A care manager can help navigate the chair process, including completing paperwork, communicating with the power chair company, coordinating payments from payer to insurance companies, confirming what level of functionality the chair must have, and securing financial assistance.

More specifically, power chairs are complex and can have an array of functions and accessories, such as being able to tilt back to relieve pressure or technology that enables users to operate them within their abilities. For example, does the patient need a joystick or another device to steer the chair? The care manager must consider these things, giving the patient exactly what they need.

2. Cultural Competence and Social Determinant Awareness

Cultural competence and understanding social determinants of health (SDoH) are key pieces of care management success; care managers must master both because they encounter a variety of people from all backgrounds.

Cultural competence allows care managers to positively interact with patients and understand their healthcare beliefs based on cultural and religious background. For example, perhaps one culture does not view pregnancy as something that would require attention from a healthcare professional, leading women to not seek prenatal care. Or, a patient may not believe in blood transfusions for religious reasons. The care manager must understand the patient’s viewpoint and respect and advocate for it.

Other SDoH include homelessness, abuse, lack of access to healthcare, unhealthy food options, financial strain, or difficult family dynamics—all of which the care manager must address in a compassionate way so that the patient feels comfortable opening up about personal barriers. A good care manager also understands that these barriers impact the patient’s ability to change behavior.

One way a care manager can practice cultural competence is by asking the right questions to understand a patient’s actual circumstances, rather than jumping to conclusions or making assumptions based on past experience or first impressions. A high-caliber care manager will take the time to get to know the patient and approach the care plan from a holistic vantage point.

3. Leadership Support

Support from leadership is critical for care management success, but lack of buy-in at senior levels is a common roadblock for many care managers. Healthcare providers and leadership haven’t always seen the value of care management, but that’s changing; organizations are now seeing that care management improves patient outcomes and lowers cost. If organizations don’t understand this value, the care manager can create opportunities to educate and inform them.

Healthcare organizations typically have a strategy for population health that includes care management. However, even if the C-suite is focused on care management, the care manager must earn the trust of the individual providers, many of whom may not have had personal experience with care management.

Care managers have to show their value to leadership through actions, and the best way to get buy-in from the top is to show leadership a successful case example—this can mean advocating for a chance to incorporate a complex patient into a care management program to show clinical leaders the benefits of care management.

Another method to garner internal support is through regular monthly updates to educate leadership and clinicians about the value of care management. Telling providers about success is not enough; care managers must show providers the value of their programs. Fifteen-minute monthly meetings to relay care management success stories (e.g., improved outcomes and lowered cost) can win over leadership and create internal care management champions at the executive level.

4. Communication Skills

Communication skills are crucial to facilitate a multidisciplinary approach between all parties—from the patient, family members, and friends to providers, social workers, and other caregivers. An effective care manager nurtures the relationship with the patient, leadership team, and providers, all at the same time, while ensuring the patient is at the center.

One part of care managers’ complex duties is to create and present a care plan that the patient agrees with, and then effectively communicate that plan to the family, providers, and other members of the care team. The care manager must nurture all of these relationships so that the entire team, both clinical and personal, is involved with the care plan and ready to play their part for the good of the patient.

5. Data-Informed Patient Prioritization

Care managers often face the challenge of a lack of interoperability due to outdated EMRs and disparate systems. Data aggregation and interoperability would be ideal for a care manager—because it provides a full picture—but it’s rarely the case yet. Many healthcare systems keep data in multiple EMRs and a variety of non-integrated sources. Claims alone does not give the full patient picture, nor does only clinical information. The identification of the correct patients for care management is a daunting task without predictive risk models and appropriate stratification tools. Health Catalyst® Population Builder™: Stratification Module helps the organization identify populations and ultimately helps the care manager prioritize patient lists and identify patients who are impactable and appropriate for care management.

With patient welfare at stake, care managers must understand the role data plays in identifying which patients are the top priority for that day. A care manager can plan the day, but interventions may change in an instant if a patient gets admitted or visits the emergency department before the care manager starts the day.

Another example would be the patient who is discharged to a skilled nursing facility (SNF). The care manager would need near real-time data to understand the patient’s functional baseline when working with the physical, occupational, and speech therapy teams to create realistic goals for the patient. Managing the patient’s functional goals is important, as a day saved in a SNF can reduce costs, prevent infection, and improve outcomes for the patient.

6. The Human Element

Although the success of a care management program depends on reliable data, the most important tool for care management success is remembering the human element of patient care. Building knowledge of the human variables that contribute to the patient’s holistic picture is part of the care manager’s responsibility.

As care managers get to know the patient on a personal level—the patient’s likes and dislikes, family situation, hobbies, history, etc.—that genuine relationship will build trust so that the care manager can guide the patient to care-plan success and optimal health.

For example, a PCP might refer a patient to a care management program because the patient is acting out of character (e.g., withdrawn, quiet, and not practicing good hygiene), but their caregiver hasn’t offered insight into these changes. The subtle signs will prompt the care manager and social worker to carefully assess the situation, perhaps revealing important information such as potential abuse, neglect, or increasing feelings of depression or isolation. Attentive, experienced care management combined with effective stratification and comprehensive patient data separates an average care management program from a superior program.

The Difference Between Good and Great Care Managers

As the nucleus of the caregiving process, care managers deal with the true complexities of each individual and must rally all of the players in a care plan around helping the patient reach optimum health. Aside from perfecting the balancing act of bringing multiple perspectives into harmony with each other, a care manager becomes outstanding when the patient’s safety, health, and well-being drive the decision-making.

It is vital that care managers exercise the six key elements to success: acting as an advocate for the patient, exercising cultural competence and understanding social determinants of health, garnering support from leadership, utilizing effective communication skills, making data-informed decisions when prioritizing patient lists, and recognizing the human element in each patient.

Additional Reading

Would you like to learn more about this topic? Here are some articles we suggest:

1. Care Management Analytics: Six Ways Data Drives Program Success
2. Identifying Vulnerable Patients and Why They Matter

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