Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost

Reducing readmissions is an important metric for health systems, representing both quality of care across the continuum and cost management. Under the Affordable Care Act, organizations can be penalized for unreasonably high readmission rates, making initiatives to avoid re-hospitalization a quality and cost imperative. A transitional care management plan can help organizations avoid preventable readmissions by improving care through all levels in five steps:

1. Start discharge at the time of admission.
2. Ensure medication education, access, reconciliation, and adherence.
3. Arrange follow-up appointments.
4. Arrange home healthcare.
5. Have patients teach back the transitional care plan.

Population Health Documentary Highlights Three Success Stories Transforming Healthcare

The documentary, “A Coalition of the Willing: Data-Driven Population Health and Complex Care Innovation in Low-Income Communities” shows how precision medicine and care management can be effective tools for successful population health. The film highlights three programs that use data to hotspot populations of high-risk, high-need patients, and then deploy unique, targeted care management inventions. The documentary, which initially aired during the 2017 Healthcare Analytics Summit, presents hopeful solutions, scalable across diverse patient populations, that are leading to exceptional results and the future of healthcare transformation.

On the Population Health and Cost Transformation Stage, Care Management Is the Star

Joe’s story isn’t a unique one in the U.S. Having been admitted to the hospital five times in one month, Joe isn’t taking his medications and doesn’t exercise. In short, he struggles to follow his care plan. The Care Management Show, an entertaining, interactive theatrical performance, demonstrates why health systems need to adopt innovative, data-driven approaches to care management that prevent patients from falling through the cracks by integrating all aspects of patient care:

• Data integration.
• Patient stratification and intake.
• Care coordination.
• Patient engagement.
• Performance measurement.

Is Your Care Management Program Working: A Guide to ROI Challenges and Solutions

Care management programs play a large part in many health systems’ population health strategies. However, these programs can consume a lot of resources. It is important to know if a care program is effective, and eventually, to show a positive ROI. Many roadblocks stand in the way:

• Complexity of Environment
• Prolonged Time to ROI
• Lack of Access to Disparate Data
• Difficulty Engaging the Patient

Why Care Management Thrives with a Program Manager

As an improvement process, care management work is ongoing. This makes a program manager an essential role in the care management leadership team—along with a governance team and physician and nurse leader. From the initiation of care management to its maintenance, the program manager ensures that strategic initiatives are operationalized and sustained. Their responsibilities include:

• Overseeing ongoing program evaluation and improvement.
• Contributing to budget planning, justification, and approval.
• Overseeing change management and program maintenance.
• Overseeing ongoing expansions to the care program.

The Modern Care Management Team: Tools and Strategies Evolve, but the Outcomes Improvement Goal Remains

The care management team concept has evolved over the last decade to be more patient- and data-driven. Truly modern care management teams—those that represent the future of care management—provide team-based care that is carefully planned, comprehensive, highly coordinated, data driven, evidence based, seamless, and patient centric. But what’s equally important as being patient-centric and patient-driven, is relying on a comprehensive, effective care management system—a suite of tools with features in five core competencies:

1. Data integration.
2. Patient stratification and intake.
3. Care coordination.
4. Patient engagement.
5. Performance measurement.

A Guide to Care Management: Five Competencies Every Health System Must Have

The goal and responsibility of every healthcare organization and provider using a care management approach is to deliver the right care at the right time to the right patients. This standard of care management can only be achieved if five competencies are in place:

• Data Integration
• Patient Stratification and Intake
• Care Coordination
• Patient Engagement
• Performance Measurement

In Pursuit of the Patient Stratification Gold Standard: Getting There with Healthcare Analytics

Even the healthiest among us would benefit from some level of care management, but resources are limited and patients must be stratified to facilitate prioritized enrollment into care management programs. Therefore, health systems need to identify not only high-cost, high-risk, and rising-risk patients, but also patients who are truly impactable. This article explains how systems can use healthcare analytics, at varying levels of maturity, to improve patient stratification and, ultimately, achieve the gold standard:

• Level 1 (where to start): use healthcare analytics to identify high-cost, high-risk patients in a population.
• Level 2: use healthcare analytics to identify patients with rising-risk profiles.
• Level 3 (highest level of maturity): use healthcare analytics to identify patients who are truly impactable (the patient stratification gold standard).

The Best Care Management Teams Empower Patients like Abdel

What do the best care management teams in the industry have in common? They engage and empower their patients to play a leadership role in their healthcare. After all, patients without the skills to manage their care incur costs up to 21 percent higher than engaged patients. Engaging and empowering patients as the most important members of the care management team makes sense on many fronts—as health systems assume more responsibility and financial risks for patients’ outcomes and costs, there will certainly be more interest in expanding the role of patients in their care. This blog explains why engaging patients like 68-year-old Abdel not only instills a gratifying sense of empowerment, but also improves outcomes and controls costs—the many benefits of an effective care management team.

How Healthcare Machine Learning Is Improving Care Management: Ruth’s Story

Healthcare machine learning, predictive analytics, and artificial intelligence (AI) are starting to play a much bigger role in care management. As care managers continue to have a growing number of patients like Ruth, who use digital devices at home, machine learning offers a solution to the resulting exponential increase in healthcare data. Defined as the practice of extracting information from existing data sets to determine patterns and predict future outcomes and trends, the advantages of using predictive analytics to improve care management are infinite, from chronic disease management to cost control. Health systems must prioritize learning how to use healthcare machine learning to not only improve their care management programs, but also outcomes for patients like Ruth.

How Care Management Done Right Improves Patient Satisfaction and ROI

A comprehensive care management program organizes many moving parts into an efficient workflow and brings order to the complex, often messy, world of healthcare. Care coordination harmonizes the workflow of clinicians, patients, family, social workers, and therapists, to name a few. It facilitates medication reconciliation, care compliance, appointment scheduling, and communication with patients, as well as engagement between patients and the care team. Care coordination concentrates on the highest-utilization, highest-cost patients to produce better clinical, operational, and financial outcomes, the bottom line goals for healthcare systems involved in population health and value-based care. This article details the benefits of, and barriers to, care management and coordination, their role in population health, and the technology that’s helping to automate this area of healthcare.

Why Patient-Reported Outcomes Are the Future of Healthcare—and the Key to Ruth’s Independence

Patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else,” are the future of healthcare. In addition to helping people like 80-year-old-Ruth continue to live interpedently, PROs—interchangeable with the term patient-generated health data (PGHD)—have several benefits:

1. Effectively supplement existing clinical data, filling in gaps in information and providing a more comprehensive picture of ongoing patient health.
2. Provide important information about how patients are doing between medical visits.
3. Gather information on an ongoing basis—rather than just one point in time—and provide information relevant to preventive and chronic care management.

The 3 Must-Have Qualities of a Care Management System

Care management systems are defined in many ways, but the only effective system comprises three qualities:

1) It’s comprehensive and includes a suite of tools to address all five core competencies of care management. 2) It’s inclusive of all EMRs and other data sources to enable thorough communication and analysis. 3) It’s analytics-driven design facilitates clinical decision making and workflow.

How Care Management Improves Performance for Clinicians, Compliance with MACRA, and Outcomes for Patients Like Olivia

As the link between performance and reimbursement in healthcare continues to grow, effective care management is key. And two critical components of effective care management are analytical tools and a multidisciplinary approach:

• Analytical tools help clinicians stratify patients by risk and need and make it easier to collaborate and coordinate care for patients (and monitor their progress over time).
• A multidisciplinary approach broadens the support patients receive, engages both patients and their families in their care, and improves medication adherence (between 40 and 75 percent of older people do not take their medications at the right time or in the right amount).

The Importance of Care Management Communication: Keisha’s Story

Ineffective communication between care providers is a major problem. According to the Joint Commission, 80 percent of serious medical errors involve miscommunication between caregivers during the transfer of patients. Care management teams need to place emphasis on good communication to effectively coordinate care and improve health outcomes. This point is illustrated by Keisha’s story, a patient who had a severe heart attack just two days after her catheterization was postponed due to incomplete information and miscommunication between her PCP, cardiologist, and nurse care manager.

The Expanding Concept and Role of Care Management: Coordinating Care for Carlos

The healthcare industry is increasingly focusing on care management, and it shows—patients with serious illnesses and injuries are experiencing better outcomes and living longer. But more needs to be done, as demonstrated by Carlos, the patient in this article who was headed toward invasive, expensive care because he had trouble being compliant with his diabetes plan. Care must be coordinated across the continuum, and tailored to the patient. The role of care management is expanding and can become more effective than ever.

The Six Care Management Challenges Healthcare Must Overcome

Most health systems struggle to succeed in care management. Whether it’s the frustrating, manual, fragmented processes or the ubiquitous lack of standardization in care management, health systems aren’t alone when it comes to the six care management challenges they struggle to overcome:

1. Fragmentation
2. Limited data access.
3. Poor data quality.
4. Limited involvement in IT and data governance.
5. Lack of standardization.
6. Limited visibility and transparency for program evaluation.

How Care Management Will Save Richard’s Life—and Billions in Healthcare Costs

The patient outcome benefits of effective care management programs are indisputable, as are the numerous economic factors driving the long overdue industrywide shift toward care management and value-based payment (VBP) models. The National Health Expenditure Accounts (NHEA) estimates that U.S. healthcare spending reached $3.2 trillion in 2015 ($9,900 per person). And as of 2012, half of American adults (117 million people) had one or more chronic conditions—the most common, costly, and preventable of all health problems. The key to addressing these alarming, unacceptable, rapidly increasing expenditures and saving the nation hundreds of billions of dollars in healthcare costs is better care management and the continued transition from fee-for-service to VBP models.

Patient-Centric Care Management Is a Strong Strategy

Care management is an important field in healthcare that ensures cost-effective, timely, and personalized care. Essentially, it gets the right care to the right patients at the right time. An effective care management system is defined by three components:

1. The fundamental of patient-centered care: understanding each patient’s individual needs, developing relationships with them, and providing tailored care.
2. The technology to deliver real-time data and support the workflows and processes of care management teams.
3. A culture of continuous improvement integrated throughout the organization. A care management platform must be supported by best practices, analytics, and adoption to lead and sustain outcomes improvement.

The Case for Care Management: Arline’s Story

Patients with complex care needs, like Arline in this real-life story, account for the highest percentage of costs. Yet, they aren’t necessarily receiving the best care. A care management program for these patients can make all the difference by helping patients and caregivers more effectively manage their health conditions. It takes time, effort, and the implementation of new care delivery models and support systems to realize those benefits, however.

Introducing the Breakthrough Health Catalyst Care Management Product Suite

Health systems are faced with the challenge of doing more than just reducing costs and improving quality of care—they must maximize their Return on Engagement by identifying and working with the patients they’ll impact the most. Health Catalyst’s Care Management Suite promises to help systems identify and improve the outcomes for these patients by delivering a comprehensive population health approach that addresses the five critical parts of any successful care management program:

1. Data Integration
2. Patient Stratification and Intake
3. Care Coordination
4. Patient Engagement
5. Performance Measurement