A growing number of state Medicaid programs are expanding managed care programs for Supplemental Security Income (SSI) eligible adults. These states are challenged with determining how to effectively design, implement, and evaluate managed care programs to meet the complex needs of beneficiaries with disabilities. In response, the Center for Health Care Strategies (CHCS) developed the Managed Care for People with Disabilities Purchasing Institute (MCPD-PI) to enhance the capacity of Medicaid managed care programs to serve the SSI-eligible population.
Care management has emerged as a primary means of managing the health of a defined population. Unlike case management, which tends to be disease-centric and administered by health plans, Care Management is organized around the precept that appropriate interventions for individuals within a given population will reduce health risks and decrease the cost of care.
The primary objective of care management is to enhance the overall quality of care and outcomes for individuals while optimizing the efficient use of healthcare resources. Care managers, often healthcare professionals like nurses or social workers, collaborate closely with patients, families, and healthcare providers to develop personalized care plans and address all aspects of the individual's healthcare needs.
A healthcare organization must identify, outline, and align models of care, including supporting categories, campaigns, and roles with the care management application implementation.
The following framework outlines and defines the key components of a comprehensive care management program and provides examples of tools and strategies that can be used by states in designing programs to effectively meet the needs of beneficiaries with complex and special needs.
|Care Management Components||Definition||Tools/Strategies|
|Identification, Stratification, Prioritization||These should be used to identify consumers at the highest risk who offer the greatest potential for improvements in health outcomes. Programs should incorporate clinical and non-clinical sources of information to identify consumers who will most benefit from care management||
|Payment/Financing||These should be aligned to support improvements in care management by rewarding consumers and providers for participating in interventions/evaluations and establishing accountability for quality and cost.||
The use of facts, analytics, and insights to influence strategic business decisions that match goals, plans, and initiatives is called data-driven decision-making process. It is a process that entails assessing data gathered via market research and developing conclusions to help an organization take better and more informed decisions.
Implementing a data-driven approach can help enhance healthcare operations, decrease expenses, generate revenues, and enhance workplace performance. To put it into practice, this entails enhancing patient care, guaranteeing prompt insurance payments, and making sure that clinical and administrative roles are adequately staffed and staff members are not overworked.
A lot of healthcare institutions now use data-driven decision-making processes. A hospital's activities in all areas are subject to process improvement and outcome evaluation.
Transitional care management (TCM) coordinates the transitions between healthcare settings to minimize patient readmissions, decrease unnecessary hospitalization costs, and increase patient satisfaction.
Implementing successful TCM protocols, an integrated data model and automated workflows helped provide a roadmap to deliver high-quality care. A roadmap to deliver high-quality care by integrating TCM protocols with an integrated data model and automated workflows powered by the Innovaccer Health Cloud. As a result, patients have a lower readmission rate of 7.3% as compared to 17.1%; Medicare Advantage (MA) patients had a lower readmission rate of 3.4% compared to 11.7%; and patients with commercial health plans had a lower readmission rate of 2.9% compared to 13.1% for patients without successful outreach. TCM has helped to reduce net readmission rates for the MSSP population by 9.8%, for the Medicare Advantage population by 8.3%, and for the commercial population by 10.2%
By adopting Innovaccer’s data-driven approach that leverages analytics, integrated workflows, and proven TCM protocols to identify risk and reduce readmissions, the organization witnessed results in better outcomes and decreased hospital costs—a win-win for the provider, the health system, and the patient. In addition, adherence to the RAF model powered by Innovaccer’s industry-leading health cloud platform led to positive ROIs and increased revenue
Assessment: Conduct thorough evaluations of the individual's health status, medical history, and social determinants of health to understand their specific needs and challenges.
Care Planning: Creating individualized care plans that outline necessary services, treatments, and interventions to address the person's health needs. These plans may include medical treatments, medications, therapy, social support, and community resources.
Coordination:Facilitating communication and collaboration among healthcare providers, specialists, and community organizations involved in the individual's care. This ensures everyone works together towards common goals and avoids duplication or gaps in services.
Monitoring: Regularly evaluating the individual's progress, tracking health outcomes, and adjusting the care plan as needed. Care managers may also provide ongoing support, education, and resources to empower individuals to manage their health effectively.
Advocacy: Serving as a liaison and advocate for the individual, ensuring their voice is heard and their healthcare preferences and goals are respected within the healthcare system.
Overall, care management, coupled with effective healthcare data management, aims to improve care coordination, enhance patient satisfaction, optimize health outcomes, and potentially reduce healthcare costs by preventing unnecessary hospitalizations, emergency room visits, and complications.
It's important to note that care management can be applied in various healthcare settings, including hospitals, clinics, home healthcare, and long-term care facilities, to support individuals across the continuum of care.
With Innovaccer’s data-driven transitional care management model, the health system had access to 360-degree patient profiles that helped in the identification of the patients at the highest risk of readmissions based on their health status, clinical events, and other metrics. To ramp up transitional care management and reduce 30-day readmissions, organizations are thus moving towards the Innovaccer Health Cloud.
Implementing successful TCM protocols, an integrated data model and automated workflows helped provide a roadmap to deliver high-quality care. A roadmap to deliver high-quality care by integrating TCM protocols with an integrated data model and automated workflows powered by the Innovaccer Health Cloud. As a result, patients have a lower readmission rate of 7.3% as compared to 17.1%; Medicare Advantage (MA) patients had a lower readmission rate of 3.4% compared to 11.7%; and patients with commercial health plans had a lower readmission rate of 2.9% compared to 13.1% for patients without successful outreach. While the, net readmission rates for the MSSP population by 9.8%, for the Medicare Advantage population by 8.3%, and for the commercial population by 10.2%.
Thus, by implementing Innovaccer’s data-driven transitional care management model, organizations can use analytics-driven care management solutions to; Improve communication with patients, Educate patients and caregivers on medication, signs, and symptoms, Improve discharge planning, Accelerate innovation across the network, Provide risk stratification for patients, Promote patient self-management and caregiver support, Reduce costs and unnecessary utilization, Advance care planning Monitor outpatient follow-ups, etc.