Navigating a medical condition can be complex – even daunting – for both patients and their caregivers. But care management, a service that offers support managing medical conditions from risk assessment through care plan development, is gaining traction as a service that can help navigate that process. Care managers, who are typically nurses or social workers, partner with patients and their caregivers, support connected communication from providers to patient, and collaborate with patients and caregivers to assess risks and needs, develop care plans, and champion self-care.
While care management provides a benefit to recipients of health services, it may also offer efficiency for the healthcare system overall. Because a care manager is involved in the overall patient case, he or she has the full context on the case, and can advise against interventions that may not be an appropriate fit. And, this connection to care equips the care manager to notice changes in conditions before they result in an emergency room visit.
Studies, like the Center for Healthcare Research & Transformation’s study of care management in senior populations, show that while care management typically improves care for patients, cost reduction can be more difficult. To ensure both patients and systems realize the care and cost benefits of care management, these care management system best practices are critical to success.
Practice Face-to-Face Contact
While a case may determine the degree of face-to-face contact required, in-person appointments or home visits are good practices. Also, care managers should attend hospitalizations and primary care visits, to ensure communication between the provider and the patient is clear, sometimes referred to as a “warm handoff,” and to receive care updates and instructions first hand.
The care manager should be engaged in all aspects of the patient’s care, and encouraging the patient and caregivers to practice the same level of engagement and commitment to the care management plan. In fact, a 2015 report by Rand Corporation found lack of engagement to be the top challenge providers faced in working with patients with chronic conditions. To encourage engagement, some plans even offer incentives, like gift cards, a lower insurance premium, discounted health club or gym memberships, or a cash payment or bonus for engagement in care management programs.
Ultimately, the care manager should approach the full group of treating professionals as a team, regardless of whether they are all employed by the same practice. To develop a comprehensive care plan, the care manager will need to develop it with the patient, caregivers and treating professionals. To understand the patient in context, the care manager will need to integrate claims data, laboratory reports, prescriptions, and goals into a comprehensive care management plan. Integration helps makes sure nothing slips through the cracks, and an established care management plan can be designed with a workflow to eliminate redundancy from providers, and eliminate the possibility of a responsibility or task going unassigned.
High-risk patients, with multiple chronic conditions, stand to benefit the most from care management as well as to realize the most cost benefits. Often, this includes the elderly. To effectively target patients, care management programs need to consider available interventions and program objectives – and then, select individuals who would benefit from those interventions and meet objectives. Acute events, like emergency room visits or hospitalizations, are often points to focus enrollment in care management programs, as they present opportunity to reduce costs as well as foster patient engagement. Predictive modeling can also help determine target populations, by understanding risks and trends that may indicate patients who would be most successful in a care management program.
At a system level, the Agency for Healthcare Research and Quality recommends that healthcare organizations benchmark metrics that will identify and monitor care management outcomes to establish success. Systems can also offer incentives for achieving goals.
Tailor Programs to Context
As with anything involving people, a one-size-fits-all approach is not best. Instead, programs must be tailored to the context in which they occur. For example, a large, urban practice can offer an in-house practice of care managers, while a small, rural practice may need to establish a network of other independent practices to build a care management team.
In addition to creating programs based on resources, programs must also be tailored to the population they are serving. For example, a care management program supporting elderly patients with chronic conditions may be best let by a nurse, while a care management program supporting at-risk populations adverse to care may be better led by a community health or social worker.
At an individual level, programs may also need some tailoring for the specific patient. Language, culture, socioeconomic status, religion, or other personal attributes can influence the care management program. This can be a dynamic process, as the patient’s needs will evolve through treatment.
Patients must be active participants in their care management programs, and care managers can support this by fostering self-management. By understanding how willing a patient is to change, as well as what resources they have available to support that change, care managers can apply motivational interviewing, and help patients set goals, monitor their progress, and take ownership of their medical conditions – and behaviors that can impact those conditions.
Patients should also be encouraged to manage their medications and identify warning signs in their health.
With advances in technology, record keeping – even across practitioners – can be much more streamlined. Electronic medical records provide immediate access to understand health risks, reduce duplicative efforts, and facilitate communication and feedback between providers.
Technology can also offer remote patient monitoring, which can improve efficiency and eliminate costs, and help connect patients more regularly through mobile phone service or automated reminders. Technology can also support patient engagement and self-management. For example, the Rand report found success using pre-written, weekly text messages to help patients with diabetes.
Focus on the Front End
With emergency visits on the rise (up by 21% from 2004 to 2014, according to an American Hospital Association study), care managers are increasingly in the vital position of coordinating the workflow in acute facilities as well as ensuring nothing is overlooked in this fast-paced environment. Care managers can support efficiency by determining if the ER is the right fit for a patient – or if they would be better suited for observations or an outpatient facility. This discernment can cut costs for the healthcare facility and ensure a better plan for the patient.
Whether care management staff is exclusively care management or serving in other roles as well, a plan for training care management staff is necessary to equip staff with the correct skillset and ensure all the positive outcomes of care management can be realized. Care managers and case coordinators should build strong interpersonal skills, to communicate with providers, patients, and caregivers alike. They should also be prepared to apply a team-based approach to care, and willingly integrate with other professionals. Often, this can be a culture change when traditional systems focus on diseases over patients and providers over a holistic team.
Training around workflow is also imperative to a successful care management practice. Care managers must be prepared for inter-professional practice, able to understand and communicate across disciplines, address a variety of cultures, and function as one part of a team.
Finally, care management practices must regularly practice introspection. One vital measure to regularly review is patient reported outcomes (PROs) to understand not only health status, but also pain, physical functionality, quality of life, and a general picture of the person. After all, care management is ultimately about providing better care for people.
One other important aspect to examine is low or no-value care systems. This could be a costlier and involved treatment that is not shown to provide a better outcome.
To understand efficiency, practices can measure avoidable emergency room visits or sensitive admissions, as these should reduce with an impactful care management program.
Evaluation doesn’t have to be shared, either. In fact, only about one quarter of results were published, according to Rand. The insights gleaned from evaluation should be used to drive process change, eliminate treatments that aren’t working, and coach care managers to improve their approach.
Although dedicating a care manager to support a patient is likely to improve the patient experience, care management must be approached intentionally, with these best practices, to truly impact the healthcare system at large.