Care management

7 Proven Ways to Drive Effective Care Management

Abhinav Shashank
Tue 07 August 2018

Imagine John to be a patient in the land of “Dream Healthcare” who has been diagnosed with Type-2 diabetes and elevated blood pressure two years ago. Every time he visited his doctor, his doctor was able to access every single relevant piece of information regarding John’s health within two clicks. The remaining 15 minutes in every visit could only be described as a true patient-physician interaction time.

After the entire visit, came the care team which remained in constant touch with John, and any irregularity in his health outcomes was closely monitored and taken care of. Ultimately, this entire John’s health saga ended with him not suffering anymore.

Seems idealistic or too good to be true? Well, it is not!

The current state of ‘Dream Care Management’

Care management is not a new concept for healthcare. It has instead gained more attention from providers and care teams since IHI Triple Aim was introduced encouraging them to improve the overall patient’s health. However, the ground reality is that still 14.8% of Medicare enrollees were readmitted within 30 days of hospital discharge in 2017.

For a nation where healthcare expenditure is expected to reach $5.7 trillion by 2026, such results are shocking. The number of hours physicians and care teams are putting in is really huge, but most of this time is spent scrolling through EHRs and excel sheets for data.

Why is effective care management such a difficult task to achieve?

Upon close examination, we can find that for most healthcare organizations, care management is full of complexities, hindering its successful implementation. According to a Commonwealth Fund report, 58% of patients do not have access to an informed and updated care coordinator.

The major challenges faced by care teams include:

  • Care teams invest a considerable amount of time in extracting patient information through EHRs and other sources since the patient’s healthcare data resides in multiple silos.
  • Without any proper tool to stratify and further prioritize the patient population, care teams remain stuck while identifying the crucial cases which are to be dealt with first.
  • Care managers are bound to work disconnected from each other. There is no proper channel to enable them to share information about their patients or schedule.
  • Members of care teams have to indulge in a lot of redundant administrative tasks such as writing letters and emails, hunting for documents, searching for daily schedules, and whatnot.
  • Care teams across the network have nearly negligible visibility into their performance. They are unable to measure the outcome of their activities, whether it might be patient health outcomes or their organizational outcomes.

How can care teams step into the world of the ‘Dream Health Care-Delivery’

Care teams hold the most critical place in care management and inefficiency in their processes is the direct inefficiency in care delivery. Many of these roadblocks are a direct result of problems associated with EHRs and the way care teams are bound to deal with it.

Here are seven ways to empower care teams to deal with the above mentioned problems:

1) Bring patient information together as a single accessible profile

Every relevant patient information should be included as a unique profile prepared by integrating each relevant data point from EHRs, CCDA documents, ADT feeds, social vulnerability data, medication history, and many more on a centralized data platform. With the creation of holistic and unique patient profiles, care teams can access any information about the patient in a single click.

2) Develop a holistic patient timeline to keep track of patient’s medical activities

Care teams should have access to holistic patient timelines so that they can understand the context of care provided to the patient by traversing through every individual patient’s timeline. This will empower them to not only understand the outcomes of the care plans patient is going through, but also assist them to decide on what needs to be done next. Through proper analysis of these patient timelines, care teams will be able to track any gap in care of the patient.

3) Prioritize and intelligently assign every patient to the right care manager

Based on the risk-score of patients or as per the specific goal of the care manager, the entire patient population needs to be stratified and prioritized accordingly. With the accurate mapping of every patient, it would become easier for care teams to assign the patient to the right care manager or coach as per their area of expertise. This would ensure seamless care-delivery to the patient and also reduce burden on the care managers.

4) Build smart worklist for every member of the care teams

Every member of the care teams should be provided with smart worklists consisting of every data on their schedules and patients. This would enable them to smartly prioritize their daily schedules to align with their goal or according to the needs of the patient. Additionally, these worklists should be collaborative to break the communication barriers among care managers, allowing them to share their patients’ information.

5) Modify care plans to suit individual patient needs

Care teams should have the ability to devise personalized, patient-specific care plans to suit every patient’s needs by incorporating patient preferences, goals, and community resources with the existing care protocols. Once the care teams learn about the looming care gaps, care teams can leverage these care plans to plug these gaps in real-time.

6) Plug care gaps in real-time with proper patient and physician engagement

It is not sufficient to merely track the gaps. Once care teams understand the interventions that a patient requires, they should have the ability to reach out to them instead of spending long hours in sending texts, emails, messages, among many others. Care teams should remain connected with the patient to ensure that their care journey is seamless.

7) Track the outcomes and assess the performance

Care managers should be able to easily track the daily productivity of their care management staff and the outcomes of care plans of every individual patient. They should be able to monitor the performance based on utilization and the average time spent by every care coach on each patient to analyze their performance. With proper tracking of care staff’s efficiency, they can be adjudged to enhance their overall outcomes.

The reform is just around the corner. We need to simply tap it.

The US care delivery mechanism is not wrong, it just requires right medication and a little healing to win this marathon to an 100% efficient dream healthcare. Providers and care teams need not to be overwhelmed with unnecessary tasks and fragmented patient information. It’s high time that care teams come out of their state of isolation, and work effectively in the most structured manner to yield better clinical and financial outcomes. Moreover, care management is all about taking that additional step towards changing the perception of patients from a care process to a care experience.


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