Welcome to Value-Based Care, Care Management.

This is Lecture a, Introduction to Care Management.

This lecture provides an introduction to care management by providing a definition,

illustrating how care management helps provide value and decrease waste in health

care spending, and providing examples and strategies of care management in action.

The objectives for this lecture are to define care management and

explain why it is central to value-based care.

Describe drivers of unnecessary or wasteful care.

Discuss how health IT can be used to support appropriate care and

decrease waste or overutilization.

Health care delivery systems throughout the United States are working toward

the triple aim as a framework to transform health care delivery.

The triple aim consists of improving the experience of care,

improving the health of populations and reducing per capita cost of health care.

To meet the triple aim and achieve the goals of health care reform,

the health care industries working to effectively treat patient populations,

while at the same time decreasing health risks and health care costs.

Care management has emerged as a leading practice for managing the health of

a defined population, which is central to each of the triple aim's three elements.

Unlike case management,

which tends to be disease-centric, and administered by health plans,

care management works toward appropriately intervening with all patients

in a given population to reduce health risks and decrease the cost of care.

Before we proceed, let's define care management and

how it fits into the overall picture of health care.

Care management is team-based, patient-centered and takes into account

the comprehensive care needs of patients and their support systems.

Care management relies on care coordination activities needed to help

manage chronic illness and the social determinants of health.

Care management has been used as a catalyst for

practice transformation as the U.S. health system moves to value-based care models.

Care coordination and care navigation are terms that are often used

to describe parts of care management specifically focused on a condition or

on the transitions between care.

But care management is the overall umbrella

which aims to improve the quality of care provided to patients

while decreasing avoidable cost associated with care delivery.

Confusion between care management, case management and

care coordination can be further complicated by the titles used for

the health care person that completes the duties of the care manager.

Care managers may be known by different titles within different health care

organizations.

They maybe called case managers, care coordinators, referral coordinators,

case navigators or other organization specific titles, and

sometimes these titles are used interchangeably.

However, that's not to say that they all do the same thing.

Case managers often have a broader role than that of the care manager, they may

bridge outside of the health care system, to address housing or other social needs.

In certain health plans, the provider assigns a group of patients to a case

manager, for these case managers, the role is to ensure that the patient group

gets the right care, at the right time, and uses a specific level of service.

The role of care coordinators involves coordinating referrals to other providers,

and coordinating care across specialists, and across health care systems.

This role can be filled by a nurse, a medical assistant, a receptionist, or

by someone else in the practice.

Care coordinators may exist in larger health systems to ease the workload of

a care manager, who often does referral functions.

A case navigator is someone who helps people navigate across multiple

care delivery systems.

They may arrange connections to financial resources,

coordinate translation services, and

facilitate transitions of care between different health care organizations.

A care manager may also perform these activities, but their role is broader.

And they try to focus on the individuals health outcomes, and

they try to help that individual manage their care as a partnership.

As background, the United States spends over $3 trillion a year in health care.

It is estimated that 25 to 30% of that spending or

almost $90 million a year is due to unnecessary care and waste.

This chart shows the main categories of waste within health care and

the relative size of their contribution.

The categories include failures of care delivery, failures of care coordination,

over-treatment, administrative complexity, pricing failures, fraud and abuse.

Instead of cost cutting strategies to save money in health care.

A better idea is to cut waste.

An enormous opportunity for

waste reduction exists in these waste categories.

Failures of care delivery results from lack of standardized best practices,

which leads to poor quality of care and poor clinical outcomes.

Failures of care coordination from missed opportunities for care intervention and

gaps in patient care, which causes fragmented care.

The result is complications, hospital re-admissions, unnecessary emergency

room visits and increased dependency for populations like the chronically ill.

Overtreatment happens when patients are subjected to the same case more than once.

Multiple x-rays, lab work, or

treatment that is not necessary leads to overtreatment and waste.

Care management helps prevent this by planning transitions of care, so that

necessarily patient health information is shared with other providers.

Administrative complexity from government, accreditation agencies or

payers creating unnecessary procedures or

rules that created administrative burden for providers and patients.

For example, building reporting tools and using the data to collect, validate,

analyze and report the data is expensive in both human time and technology.

Pricing failures happen when health cost is not transparent in

a competitive market.

Fraud and abuse from fake bills or scams for health care procedures or

treatment are falsified.

Such as when billing for services not rendered, billing for

non-covered service as a covered service, or kickbacks or bribes occur.

Care management can contribute to the reduction of waste in many of these key

categories.

What does reducing waste look like in the health care system?

In order to reduce waste, the health care system is building effective and

efficient systems through the development and

implementation of evidence-based guidelines.

Provision of clinical decision support, adoption of team-based care models,

redesign of the system and workflow, integration of care management.

For instance, the Choosing Wisely campaign is aimed at driving waste out of

the health care systems by following evidence-based care guidelines.

Specialty organizations created lists of recommendations that provide

evidence-based guidelines regarding when not to offer certain tests and procedures.

And the campaign provides a resource for

care providers to follow evidence-based guidelines.

When followed, these practices serve to drive out waste in care delivery.

Another way to incorporate evidence-based medicine is to integrate it

into decision support tools provided through health information technology or

health IT systems.

Such integration allows the provider to see the recommendations

at the point of care, which supports the reduction of waste.

Health care organizations are redesigning work flows to be more efficient.

These workflows more effectively support the care team and the patient and

build better care experiences through efficiency to reduce waste.

Care management functions help the patients to manage their conditions more

effectively.

The structure of care management and care teams help individual care

team members work at the top of their license, providing the best care possible,

while avoiding unnecessary care that wastes resources.

This is one way that care management decreases waste in health care.

Finally, integration of care management into health care delivery

provides a mechanism for doctors, nurse practitioners, physician assistants,

nurses, psychologists, social workers and other members of the care team

to all provide care and support to patients as a seamless team.

How do we address these health care waste areas and unnecessary care?

Through value-based care and successful strategies like care management.

For example, using primary care services more effectively,

consistently, and broadly.

Utilizing a primary care team with care managers at the helm to allocate resources

more effectively contributes to reducing waste and unnecessary care.

Care managers can encourage and guide care teams toward more evidence-based

care that looks critically at outcomes and value.

Patients also receive the enhanced care management services they need to become

and stay healthy.

Health care waste must be addressed on both the supply and

demand sides of the equation.

Looking first at the supply side,

we have alternative payment models being used by providers.

On the demand side,

We have consumer-directed health plans that provide coverage based on outcomes.

These both can be utilized to eliminate waste in the system and yet

avoid a hard trade-off between cost, quality, and care.

Care management can support both sides, supply and demand.

And at the same time, support the care team and the patient.

All of these could combine to save healthcare resources and

eliminate waste in the system.

These measures avoid the hard trade-off between cost, quality, and care.

Care management programs may include but are not limited to, complex

care management programs, aimed at a subset of patients whose critical event or

diagnosis requires extensive use of resources.

And who need help navigating the system to facilitate appropriate delivery of care

and services.

Transitional care management programs focused on evaluating and

coordinating transition needs for patients who may be at risk of rehospitalization.

High-risk and high-utilization programs aimed at patients who frequently use

emergency department, or ED services, or

have frequent hospitalizations at high-risk individuals.

For example, patients dualy eligible for Medicare and

Medicaid, or patients who are institutionalized.

Hospital care management programs designed to coordinate care for

patients during inpatient admission and discharge planning.

Patient centered medical homes organize primary care through coordination and

communication to transform care toward patients satisfaction,

increased quality, and lower costs.

Care managers support the broader strategy of value-based care

by helping an individual use services at the right time.

And improve health behaviors and outcomes based on modifiable risk.

For example, a care manager within a health care home setting helps the patient

know when they should go to the emergency room, when to go to the clinic, when to go

to the hospital, or when to try to manage their symptoms on their own at home.

By helping and coaching the patient to choose the appropriate level of care,

the care manager helps decrease unnecessary high cost medical care,

which in turn provides value.

As the US health system moves from volume of care to value of care, care

managers help both the patient and the care system utilize resources effectively.

As the centers for Medicare and Medicaid services are starting to reward value

through care coordination, care management has become more important.

In some payment models, care management is a billable service.

This creates greater incentive for care management.

The goal of care management is to help patients regain optimum health or

improved functional capability, cost effectively and in the right setting.

For example, by making sure patients see their primary care provider at the onset

of symptoms rather than going to the After the issue has exacerbated.

It involves comprehensive assessment of the patient's condition.

Identifying barriers to care, determining current benefits and needed resources,

developing patient goals, and monitoring mechanisms and follow up.

The following story illustrates how a care manager can help a patient achieve

better outcomes.

The patient's name is Barry.

He was overweight, depressed and has diabetes.

Barry's multiple conditions prevented him from carrying out the activities of

daily living.

After losing his health insurance, Barry used the emergency department or

urgent care for his immediate care needs.

But his chronic conditions and overall health were not being addressed.

A non-profit in Barry's community enrolled him into a care management program to

address his multiple chronic conditions.

As part of that program, a care manager was assigned to him.

The care manager helped coordinate the services of the different specialists who

addressed Barry's conditions.

The care manager coached Barry by providing him with

education about his medical condition.

And actions that he could take to self-manage his health.

Barry's care manager connected with him every week.

Together, they set achievable goals for the week, including exercise routines,

nutrition, sleep patterns, and medication delivery.

Through the process, Barry was better able to control his eating and exercise habits,

establish better sleeping routines, and take his insulin regularly.

These changes allowed him to feel more in control of his life and

improve his self management of his diabetes.

He was able to become more active, thus improving his depression.

He was able to stay on his medications more consistently and

to regain his health insurance.

Having his insurance back meant he didn't have to struggle with not having coverage

for his medication.

Barry's progress toward his goals came along with the support of his care manager

and the care team.

And resulted in a reduction in Barry's overall cost of care.

This is a great example of how care management,

as part of a value-based care delivery model, supports an individual's

health outcomes, particularly one with multiple chronic conditions.

Care management allows an individual to have a customized plan of care,

just as we saw with Barry.

His care was customized to his capability and based on identified gaps in his

care and opportunities identified by the care manager.

His ability to manage his care progressed over time and he became more empowered.

In a value-based care model

the care manager helps the patient receive the appropriate level of service,

in the right setting and at the right time, that matches his needs.

The care manager communicates with the right care team member at the time it's

needed and provides documentation of gaps, interventions, and outcomes.

By documenting goals, interventions, and outcomes,

the care manager can also track and report on improvement over time, and

provide encouragement to the patient to continue with a healthier lifestyle.

For all of these reasons, the care manager helps patients achieve better outcomes and

the facility actualize a value-based care approach.

Care management allows an individual to have a customized plan of care,

just as we saw with Barry.

His care was customized to his capability.

And based on identified gaps in his care and

opportunities identified by the care manager.

His ability to manage his care progressed over time and he became more empowered.

In a value based care model,

the care manager helps the patient receive the appropriate level of service,

in the right setting and at the right time that matches his needs.

The care manager communicates with the right care team member at the time its

needed and provides, documentation of gaps, interventions and outcomes.

By documenting goals, interventions and outcomes,

the care manager can also track and report on improvement over time and

provide encouragement to the patient to continue with a healthier lifestyle.

For all of these reasons, the care manager helps patients achieve better outcomes.

And the facility actualize a value based care approach.

The second key strategy is the alignment of care management with population needs

to promote supportive trusting relationships between providers and

patients.

A critical component to successful delivery of primary care and

of care management.

Key services directed towards the needs of particular populations

include coordination of care, self management support and outreach.

Care coordination can include referral tracking and

follow up on specialist encounters.

Goal setting, motivation interviewing, regular check-ins,

education and personalized care plan development.

Personalized care plans allow interventions to be tailored to individual

patients based on their preferences and personal health goals.

Electronic care plans can be printed or shared with patients,

who can intern share that document with specialist or an emergency department.

Some medications, allergies, problem list and lab results are readily available.

And there is no need for duplicate efforts.

Self management and patient engagement can empower patients as they move toward

behavioral change that targets their unique modifiable risk.

Outreach to patients through planned contact to provide education, support and

resources enables care managers to track progress and

provide additional services that are timely.

To most effectively document track and

monitor progress, an electronic health record or EHR should be used.

Finally, care management strategies should include the identification and

training of personnel to provide services.

Practices can either assign a dedicated care manager to a patient.

Or they can provide care management through the use of an inter disciplinary

team, available staff resources, along with the target population's clinical and

psychosocial needs.

Will influence the background and

training of personnel selected to deliver care management services.

Different skill levels may be appropriate for

the different care management services.

In selecting patients that are appropriate for care management,

the aim is to identify individuals from a stratified population.

Who are at the highest risk for poor outcomes, our high resource utilizers or

would benefit from planned care management interventions.

Patient selection relies on data analytics and predictive modeling statistics,

which draws the data from the EHRs being utilized in care delivery settings.

Common approaches for selecting patients for

care management include quantitative risk prediction tools,

that identify a subset of high risk patients using insurance claims data.

Acute care utilization, that is focused on individuals

in a stratified population that have a high number of hospital admissions.

High risk condition, which identifies individuals

who have high cost care patterns based on medical or mental health conditions.

Medication utilization or spend, which is focused on pharmacy cost and

high cost medication utilization.

Health risk assessment, which brings data together from multiple sources to

identify individuals with a profile of high risk health conditions.

Health information technology or

health IT, is often used to facilitate communication of patient information

within individual health care organizations.

And helps providers to make informed care decisions.

For example, by using information provided through an electronic health records or

EHR system, a care manager could document and

then access more information about the patient.

The care manager could electronically document what's happening

with the patient, to develop a care plan by recording the patients goals and

documenting the patient's progress to those goals and the outcomes.

This information could then be made immediately available to

all care team members.

Teamwork is facilitated through face to face meetings and

use of a shared information technology platform for secure communication.

The EHR is a comprehensive database of a patients health information.

It not only shows historical information but also shows the care management that is

happening amongst team members in real time.

Quality measurement, is another critical element to the strategy to

improve the quality of care delivered in the U.S. health care system.

In value based payment models,

payments are made based on meeting performance goals and quality metrics.

If data is accurately reported in a EHR platform,

then the healthcare provider can be properly compensated.

In fact, most risk sharing arrangements require the monitoring and

reporting of quality metrics.

Outcome measures are sent to federal and state agencies.

Health plans also gather outcome database on claims and medical record audits.

Outcomes are used for payments but are also reported publicly, so

that patients can make inform decisions about where they received care.

Additionally report data can help a care manager identify which patients are doing

well and which patients may need further care,

these specialized reports can also be used for disease registries.

Health IT as part of care management can also support

appropriate resource utilization.

For example, when ordering an MRI or a CT scan, the provider uses

decision support and shared decision making tools with the patient.

To discuss their options and offer treatment that is evidence based,

they let the patient know the recommendation based on the evidence.

Then the provider can ask the patient what's important to her and her health.

This approach utilizes the most appropriate level of care and

supports the patients goals.

Care teams and

care managers use registries to manage cohorts of patients for population health.

For example,

a diabetes registry which shows the care manager the blood sugar levels for

a group of patients with diabetes, can be used by the care manager to make decisions

about which patients may need attention based on their blood sugar levels.

This allows the care manager to focus attention on patients that need support.

It also allows the care manager to report that information

in order to participate in value based payment models.

Health IT also provides value by allowing the exchange of information

between care management sites such as between a hospital and a nursing home or

between a clinic and hospital.

Information exchange can prevent readmissions or duplication of services.

This concludes lecture a of care management.

In summary,

care management is a central concept to value based care delivery models,

applying care management practices is a way to reduce waste in U.S. health care.

Strategies for implementing care management include identifying populations

with modifiable risks, aligning services to the need of populations and

training appropriate personnel for needed services.

Leveraging health IT to access patient data and facilitate electronic document

exchange, will help to achieve the goals of care management.

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AUDIO]

Introduction to Care Management

HI-FIVE: Health Informatics For Innovation, Value & Enrichment (Clinical Perspective)

Meet the Instructors