Enhancing Mental Health Care Transitions Reduces Unnecessary Costly Readmissions

Nationally, hospitalization for persons with mental health disorders has increased faster than hospitalization for any other condition. Of concern is the lack of bed space to intake these patients on a timely basis. In Minnesota, for example, more than 50 percent of available state psychiatric beds were closed between 2005 and 2010. Furthermore, readmission rates for patients with mood disorders is higher than any other mental health condition, with 15 percent readmitted within 30 days of hospital discharge and up to 22.4 percent of patients with schizophrenia being readmitted. While the average cost of a readmission in the U.S. is approximately $7,200, of greater concern is hospital readmission represents poor patient outcomes related to lack of adequate access to community mental health resources and challenges with adherence to care plans needed to prevent chronic relapse.

In response to these challenges, Allina Health put a new care transition process in place, redesigned workflow, and added key patient support roles. To measure the effectiveness of new interventions, Allina relied on the Health Catalyst Analytics Platform, which includes the Late-Binding™ Enterprise Data Warehouse and a broad suite of analytics applications.


  • 27 percent relative reduction in potentially preventable readmission rate.
  • 80 percent patient retention rate in established outpatient mental health services.
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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


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

A thoughtful approach and a robust analytics platform can help organizations overcome these challenges. Care management ROI should be a long-term strategy, but cost savings and quick wins are possible using the Health Catalyst® Cost Management Suite.

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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.
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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.

As the industry’s care management teams continue to evolve (e.g., using predictive analytics to proactively identify patients), their primary goal remains: achieving optimal outcomes for the patients they serve.

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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.

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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

This guide to care management reviews each competency and shows how to put it all together into an effective program that gets results for organizations and patients alike.

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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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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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