By ABHINAV SHASHANK

Emma Jones, 67 was diagnosed with Type-2 diabetes and morbid obesity five years ago and had always faced issues managing her HbA1c levels and morbid obesity. Her last test report revealed her HbA1c to be higher than the ideal and her obesity , barely controlled. Emma's PCPs and specialists knew that the problem was related to her poor adherence to care plans and irregular follow-up visits. Apart from her wellness and health, the secondary concern for the providers was facing the growing emphasis Medicare had placed on overall performance and its link with reimbursements.

Care management in the era of Value-based reimbursement

The idea of care management has been part of the healthcare space for years. However with the growth of value-based incentives and risk-based contracting, healthcare providers have further increased their focus on improving outcomes and ensure patients get the right care at the right time.

Value-based reimbursement models push providers to strive to provide the best care and offers rewards for improvements in outcomes, efficiency, and wellness in an evidence-based, cost-effective manner. Effective care management is an important tool that focuses on patient-centric care and generates a quantifiable ROI to contribute to a healthcare system's bottom line.

What should care management entail?

In a nutshell, care management comprises of all the activities performed with the aim to improve patient care and helping caregivers manage health effectively post-discharge. Providers have lately started leveraging health IT to make the entire care management plan comprehensive and improve outcomes by a wide margin. Deep diving into it, a care management tool should entail following features:

• Data integration: The care management tool should have the ability to ingest data from multiple data sources, aggregate, and bring it together into a single patient record.
• Risk stratification: Leveraging advanced analytics to identify high-risk, high-need patients to help providers with prioritizing and delivering care to patients who need it urgently.
• Patient engagement: Patients should be informed and made aware of their health and be encouraged to adhere to their care plan and associated activities through targeted engagements.
• Outcome measurement: Healthcare organizations should have an understanding of what is spent on their care management program, how effective that program has been, and what will drive better outcomes in the future.

The case for a multidisciplinary, coordinated approach

According to a survey, 44% of high-need patients face major coordination problems after being discharged from a facility. Moreover, no two patients pulled into a care management program would have the same needs. The care teams need a way for rightsizing every patient and employ a multidisciplinary approach:

• Stratify patients: The care management tool should be able to stratify patients on the basis of risk scores, chronic conditions, social determinants of health using information from socioeconomic, clinical, claims, and other data feeds.
• Assign health coaches: Once the patients are stratified, prioritize and assign care teams and health coaches by need and availability.
• Patient-specific care plans: Patients should not be treated as an average but as an individual. The care teams should aim to develop tailor-made care plans, suited to their needs and improve care via targeted interventions.
• Coordinate efforts: Members of care team could help coordinate all available resources like specialists, educators, dieticians, pharmacists, etc. to manage a patient's health better.
• Broaden support: A multidisciplinary care team would help in comprehensive care management and engage both patients and their families in the treatment plan and aim to reduce medication non-adherence.

Care management contributes to Population Health Management

Comprehensive, end-to-end care management undoubtedly has a significant impact on patients struggling with more than one medical condition. Health systems and organizations have begun to redesign their care management programs that address the struggles patient's face and make care delivery a successful experience. Population health management is all about improving clinical and financial outcomes, and it is not possible without effective care management. Providers should aim to work towards that and leverage all the tools at their disposal to easily coordinate care for patients and improve their lives, one patient at a time. A complete care management model is what healthcare providers should employ to improve healthcare industry and population health as a whole and obtain better outcomes at lower cost, driven by value.

Abhinav Shashank, Co-Founder & CEO at Innovaccer, is an expert in population health management and robust technologies. For the better part of the decade he has been working to revolutionize healthcare delivery with 25+ value-focused organization and making over 10 million lives better. Visit www.innovaccer.com