Integrated Care Management – Improves Care and Population Health While Reducing Costs

One hundred thirty-three million Americans, 45 percent of the population, have at least one chronic disease. Chronic diseases are responsible for 7 of 10 deaths each year, killing more than 1.7 million Americans annually. Moreover, chronic disease accounts for 86 percent of our nation’s healthcare costs.

An integrated delivery system and an accountable care organization with two large academic medical centers and six community hospitals, Partners HealthCare is increasingly compensated for outcomes of care. Recognizing the need to more effectively manage its chronically ill patients, Partners implemented an integrated care management program (iCMP) to improve the outcomes of rising-risk patients and better manage treatment costs. The iCMP is a primary-care embedded, longitudinal care management program led by a nurse care manager working collaboratively with the primary care provider and care team.

The iCMP is contributing to Partners effective management of patients and financial success in at-risk contracts. In its Pilot Phase as a Medicare Demonstration Project, the program achieved the following results:

  • 20 percent lower hospitalization rate per 1,000 patients.
  • 13 percent lower rates of emergency department (ED) utilization.
  • 25 percent relative difference in mortality.
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Care Management: A Critical Component of Effective Population Health Management

Unprecedented changes in the healthcare payment system have resulted in health organizations across the country investing in the pursuit of the Institute for Healthcare Improvement’s (IHI’s) Triple Aim to improve population health, improve patient experience and outcomes, and reduce costs per capita. Health organizations must develop effective population health management strategies, and they need the right data and analytics to inform their initiatives.

Once armed with the information to make data-driven decisions, leading healthcare providers are implementing care management programs, which have proven to be helpful mechanisms for achieving the Triple Aim. Many healthcare organizations have identified specific patient cohorts to monitor the impact of care management interventions on individual and population health outcomes.

Data-driven care management programs that target high-risk and rising-risk patients can achieve impressive results, including:

  • Up to 20 percent lower rates of hospitalization in mature care management programs.
  • Lower rates of emergency department utilization.
  • Decreased costs.
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Other Content in Care Management and Patient Relationships

Posts

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).

Analytics is key to achieving the patient stratification gold standard, but should enhance (not replace) clinical judgement. Stratification lists need to go through workflows in which clinicians remove patients that aren’t appropriate for enrollment.

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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.

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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.

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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 new technologies that enable PROs and PGHD (e.g., sensors that detect whether Ruth takes food out of her refrigerator on a regular basis), generate important data outside of patients’ traditional care environments, sharing it with care teams to expand the depth, breadth, and continuity of information available to improve healthcare and outcomes.

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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.

Ultimately, an effective system improves outcomes and becomes an indispensable tool for managing population health.

This article describes what drives successful care management, and reveals a suite of applications that aid care team members and patients through advanced algorithms and embedded analytics. Learn how technology is helping to develop appropriate interventions and improve clinical and financial outcomes.

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Product Demos & Literature

Patient Intake (Product Demo)

Patient Intake is built to streamline the process of patient intake and care team assignment. It delivers an efficient way of consolidating and managing multiple lists, collaborating with the physician and reaching out to these patients so the real work of delivering care can be done. Users can add, update or remove patients from the list before routing the patient record to the next person in the workflow. This application is required when deploying Patient Stratification as a patient list source for Care Coordination.

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Care Coordination (Product Demo)

Care Coordination is a mobile, tablet-based application, used at the point of care by care coordinators and team members to organize patient interventions including shared decision making for patient goals and activities, patient and team communications, as well as alerts and notifications for new admissions or decreasing patient engagement activity. It is important that the entire care team, along with the patient, and the patient’s family and friends, can communicate through the care management solution to develop relationships that help or encourage patient engagement. Health Catalyst’s mobile-first approach enables the care team to go where the patients are: their homes, physician offices, post-acute and long-term care settings. The solution supports all members of the care team including social workers, community resources, care navigators, etc. across multiple EMR systems.

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Patient Stratification (Product Demo)

Patient Stratification integrates current and cost trends, chronic conditions, and social determinants risk models and disparate sources to identify the individuals most likely to benefit from proactive care management programs. Users can build and analyze different stratification algorithms based on proven risk models and patient utilization to rank and ultimately determine the most important candidates for intervention through complex care management, chronic condition management, readmission prevention or other programs. Current care management solutions deliver static lists of patients who meet certain population health criteria, without actionable information on how to treat them. Health Catalyst’s Patient Impact Predictor™ enables identification of people who may fall anywhere along three levels of care management but who are most likely to benefit from specific interventions that have worked effectively in the past for similar patient types.

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Webinars

Partners’ Care Management Strategy: A 10-Year Journey

Chronic diseases are responsible for seven out of 10 deaths each year, killing more than 1.7 million Americans annually. Additionally, 133 million Americans—approximately 45 percent of the population—have at least one chronic disease. Partners HealthCare believes that chronically ill patients with multiple medical conditions often need the most help coordinating their care, which is why this well-respected health system has spent the last 10 years perfecting an integrated care management program (iCMP).

Key elements of the iCMP at Partners include access to specialized resources (e.g., mental health, palliative care), involvement through the continuum of care, patient self-management, IT-enabled systems to improve care coordination, data-driven analytics to support strategic decision making, a payer-blind approach, and ongoing support and training for its teams and staff.

Attendees will learn how to:

  1. Identify the essential elements of an effective care management program for chronically ill patients
  2. Recognize how care management plays a key role in an effective population health management strategy
  3. Determine how to use information to identify and effectively manage complex, chronically ill patients
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Introducing the New Health Catalyst Care Management Suite: Solving the Patient Engagement and Outcomes Challenge with Innovative Data-driven Workflow

Earlier this year Russ Staheli, SVP and Product Line Manager – Population Health presented a vision around how Care Management can help drive your system to this triple aim. He is back to discuss the formal release of our brand new suite of tools that represent the first end-to-end care management solution in the industry and the first to enable discovery of an otherwise invisible subset of patients – those who will benefit most from care management and who can be engaged most effectively to lower the cost of care.

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