What Is Care Management?

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 software 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.

Care Management Framework

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 ComponentsDefinitionTools/StrategiesIdentification, Stratification, PrioritizationThese 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

Health risk assessments
• Predictive models (algorithm–driven model that uses multiple inputs to predict high-risk opportunities for care management)
• Surveys
• Referrals (from members, provider, community)

Payment/FinancingThese 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.

• Pay for performance at multiple levels (e.g., health plan, provider, and consumer level)
• Share in program savings (gainsharing)