The Importance of Data-driven Care Management in Becoming Patient-centric

Care management, on its surface, seems an efficient way of tackling skyrocketing costs in healthcare and providing patient-centric care. Risk stratification, for instance, has emerged as one of the most significant reimbursement determinants for providers. This requires complete data and sophisticated analyses in place. Any network leakage or inaccessible data can influence the ROI for providers drastically. Generating meaningful insights has become an indispensable part of not just value-based service model, but a roadmap to enhance healthcare efficiency as well.

Challenges with care management today

With data residing mostly in siloes, generating the actionable insights necessary to provide intelligent, seamless care is incredibly difficult. The data gaps are wide and providing care across the continuum becomes a grueling task with complicated EMRs and fragmented patient records. The ever-expanding need for alignment amongst different service providers is challenging even with sophisticated care management models, leading to lower overall reimbursement. Much of the problem can be attributed to insufficient data and automated tools that can deliver a risk-stratified outlook.

Chronic Care Management, specifically, has substantial room for improvement since patients with chronic and high-cost conditions need end-to-end medical, behavioral, and social care across the care service spectrum. Around 45% of the Americans suffer from at least one chronic disease, yet the lack of structured data results in making the patients’ care journey expensive while generating less margin for providers. For example, according to a recent survey, less than 20% providers were actually paid for their 99490 claims, a CPT code for “non face-to-face care coordination services”.

Automation in Integrated Care Management

The primary criterion that all care management models should fulfill is to support real-time analytics. In an industry as dynamic as healthcare, the patients’ care journey should be tracked and updated continuously- including test reports, ER visits, and beyond. It is important to ensure that all the service providers are at the same level at any particular time as far as their patients’ statuses are concerned. Yet another challenge is to ensure that the work output of the care teams is optimized. Their observations may not turn out to be as accurate if large siloed data pile-up to create coding gaps. It might also create voids in providing adequate care thereby reducing the potential of development in that system. The limitations faced by the care teams while comparing the cost-effectiveness of the various care programs may lead to certain unnecessary expenditures that could easily be cut back.  Binding the care teams together through a holistic dashboard is the first step in the direction of improving the care management. We developed a Patient 360 module, which provided a holistic view of an individual’s health,  keeping this very thing in mind. Interoperability and remote-access were two other features we focused on.

A care management platform should assist the providers in the most user-friendly manner so that the shift from conventional record systems becomes easy. Ultimately, it all comes down to improving the quality of care by reducing unnecessary paperwork. For example, with Patient-360, care teams can have a complete assessment of the patients including their vital signs, ailment archives, risk scores, active care plans. An all-inclusive database is created by compiling data from numerous incongruous sources to provide the care team with easily accessible patient statistics that are regularly updated. This helps them bridge gaps and eliminate care voids. Additionally,  the Patient 360 records can be viewed on visually-adaptive dashboards and are available to all the associated providers, across the system.

Care teams should be able to monitor abrupt spikes in risk scores, details of admissions or discharge, and the consequences of care programs across the continuum. This would enable the providers and care managers document their dealings with the patients, track miscoded diagnostic codes, and estimate a concrete impact on proceeds and risk-adjusted reserves within EHRs. Simply put, integrated systems are one of the better ways of helping in maintaining healthcare and wellness of the patients. Access to information such as the medical history of the patients, social determinants, risk scores doesn’t only help the providers in making sure that the patients recover from illness, but also helps in preventing potential illness symptoms to some extent by giving providers real-time actionable insights.

Advance follow-up mechanisms and need for real-time updates

Two critical terms used in healthcare IT industry nowadays are iterative models and predictive and prescriptive analysis. What they aim at achieving is, again, patient-centric care. Innovaccer’s care management module, InCare, for instance, gives providers the option of prioritizing their patients based on their risk-scores or schedule. Similarly, work queues can be generated based on the availability of the patient and provider, demographic factors, conveyance available, and so forth. Customizable care plans added with automated outreach mechanisms like calls, texts, and even providing transportation on a single click is something we have really worked hard on, and it has paid rich dividends. It is an all-inclusive, end-to-end solution that incorporates an extensive range of provisions intended to improve patient care. It not only efficiently manages health conditions but also reduces the complexity of tedious tasks and hence ensures less effort and more time-effectiveness.

For recently discharged inpatients and patients with chronic diseases, following-up is an integral part of the entire care management process. For health coaches and managers alike, it is essential to not only prioritize their patients but also categorize them uniquely, something that we call Enterprise Master Patient Index (EMPI). Our data integration platform matches patient population on numerous factors such as clinical and social risk scores, geographic proximity while taking into consideration the schedules of care managers. This helps in assigning every particular patient the best care teams to provide optimum care. It ensures that a personalized care program based on patient preferences and goals is delivered. Several in-built care programs, which work on alerts and triggers, are designed in collaboration with leading health experts and care teams.

Automated follow-up mechanisms help in avoiding the “inescapable trap of care loop.” More often than not, the follow-ups get confined to assuring that revisits to the physicians are on time. Instead, follow-ups should do the exact opposite purpose- ensuring that revisits to clinics or ERs are avoided, or at least reduced. With real-time analytics, all the providers can track the condition of the patients and can share insights as and when required.

Impact measurement and analyzing “Spend Vs. Savings” of care plans

To enhance healthcare efficiency, it is important to track patients’ health on a real-time basis to serve two basic purposes-

Evaluate the improvement in patient’s health.

Keep track of the work output and efficiency of care managers and recompense them for a noteworthy performance, and motivate them with proper incentives.

Measuring the impacts of care plans is a vital component of the entire care journey. Keeping a check on the expenses incurred by the patients is important for the providers and payers alike. The interaction with patients, therefore, should be meticulously documented by the care managers. An IT integrated platform can help them with evaluating the impact of care mediates on their vitals and risk scores. Additionally, it should be ensured that the care managers are always updated with the latest and the most current developments in the patients’ health. They should also be able to make required modifications in the ongoing core programs to address their dynamic and ever-shifting requirements.

With an integrated data platform in place, care teams can monitor abrupt spikes in risk scores, details of admissions or discharge, and the consequences of care plans. This enables the providers and care managers document their dealings with the patients, track miscoded diagnostic codes, and estimate a tangible impact on proceeds and risk-adjusted reserves within EHRs. This helps in reducing unnecessary costs that may pile-up to make a significant chunk of the total cost. With all the details documented holistically, the efficiency of the care managers can also be adjudged to encourage them for their performances.

The Road Ahead

Care teams have long been overwhelmed with high administrative burden and fragmented patient information- and even the most well-structured care teams cannot yield better clinical and financial outcomes in isolation. Having access to accurate, complete, and timely data is an important starting point, and it has to be paired with the ability to understand what the data is saying. It’s high time we integrated data to create accessible outcome-driven insights that can translate to effective strategies. It’s time healthcare organizations created a strategy that connects systems and helps patients navigate the complexities of care. After all, care management is really about collaborating efforts and addressing those gaps that go beyond the four walls of a hospital.   

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