According to a report from the Centers for Disease Control and Prevention, Americans living with chronic physical and mental health conditions account for 90% of the $3.3 trillion the U.S. spends each year on healthcare. Appropriate care management can help healthcare organizations lower those costs, while improving care quality and efficiency.

The Definition of Care Management

Care management refers to a comprehensive suite of services and activities that help patients with chronic or complex conditions manage their health. Care management’s overarching goal is to improve patient health. To get there, the model also aims to improve care coordination, reduce hospital visits and boost patient engagement. Care management software can significantly support healthcare providers meet those goals.

Comprehensive care management demands a team effort. Physicians, clinicians, patients and their caregivers must all work together to help patients take control of their complex health needs.

Elements of a care management program include some or all of the following:

  • A dedicated care team
  • A comprehensive care plan
  • Medication and care-management tools
  • A hospital-to-home program
  • Patient education materials
  • Expanded communication between patients and healthcare professionals
  • Care coordination with community and home-based service providers

Benefits of care management typically include:

  • Improved clinical outcomes
  • Reduced use of high-cost acute care services
  • More primary and/or preventive care visits
  • Fewer duplicative tests and procedures
  • Higher patient satisfaction

Components of a Comprehensive Care Management System

At its highest level, care management in healthcare is a natural extension of primary care. To make that ideal a reality, however, a comprehensive care management program requires complex coordinated interplay among all healthcare stakeholders, from practices, health systems and care teams to caregivers, patients and their communities.

Launching a care management program requires the following components:

  • Community resources. Partner with local community organizations to develop interventions that fill gaps in patient care. Encourage patients to participate in community health programs that can improve or help manage their condition or disease.
  • Value-based care. Because of its focus on improving outcomes and lowering total healthcare costs, comprehensive care management fits well into a value-based care model. Healthcare organizations and certain providers that use this model can bill the Centers for Medicare & Medicaid Services (CMS) for care management services. CMS calls this program Chronic Care Management (CCM). [Note: Qualifying healthcare providers that participate in fee-for-service Medicare programs also may bill for CCM services. This CMS guide includes detailed information on the CCM program, as well as CCM service codes.]
  • Care coordination. Organize dedicated care teams that regularly communicate and collaborate on patient assessments, treatment, interventions and care planning for patients with chronic and complex conditions. All care team members should have defined roles. This level of care coordination also requires systems and strategies to reduce duplicative services.
  • Data collection, analytics and integration. Pull and aggregate data from patients’ electronic health records (EHRs), claims data and other sources. Use analytics software to sort through relevant data that can identify patients who could most benefit from care management, including those with chronic diseases or high-risk, high-use patients.
  • Decision support. Educate providers, clinicians and staff about how to talk to patients about the program. Use visual aids to enhance communication with patients and team members. Examples might include posting guidelines in exam rooms, or providing team members with assessment forms to guide their decision-making, as well as flowcharts and checklists that can help them effectively implement the program.
  • Patient engagement and self-management. Develop strategies to encourage patients to actively participate in the program by providing them with tools to help manage their chronic conditions. Those tools might range from an insulin vial-tracking log to at-home blood-pressure monitoring to a healthy cooking workshop. Patient engagement should also include regular communication through a variety of mediums, from secure patient portals to reminder texts. A JAMA Internal Medicine study found that text messaging could improve patient medication adherence by 17.8%.
  • Performance measurement. Implement technology and systems to track care team performance as well as patients’ health. For instance, how much did A1C levels improve in patients with type 2 diabetes over the past 12 months? Or, how much time did nurse practitioners spend on care management activities?

Care Management Software

Care management software can help healthcare organizations streamline their care management efforts. Many products can be scaled up to meet the needs of large health systems or scaled down to suit smaller primary care practices. In all cases, however, EHR integration is paramount.

Software products and features to consider include:

  • Analytics. These are tools that help providers identify target patient populations and track outcomes and performance
  • Patient Intake. A comprehensive patient intake management solution automates and streamlines many tasks that support care management programs, including mobile registration, collection of patient-reported outcomes data, patient outreach, and analytics.
  • Care Plan Creation. This tool aggregates data and allows care managers to create comprehensive care plans tailored to individual patients.
  • Patient engagement. These tools provide(s) a patient portal, secure messaging, educational resources, appointment reminders and other patient-centered features.
  • Care coordination. This software platform gives care team managers pre-visit planning tools and predictive-risk stratification, as well as patients’ admission, discharge and transfer-tracking data.
  • Clinician coordination. This application tracks the amount of clinician time spent on care management appointments and activities.
  • Reporting. This tool tracks a care management program’s progress over time.

Conclusion

Care management has emerged as a leading practice-based strategy for managing the health of populations with complex or chronic medical conditions. By incorporating systems, science, information technology and encouragement, care management programs can raise the quality of care and help patients improve and maintain better health.

Find out how Phreesia’s clinical support offerings help our clients enhance quality and improve patient outcomes.