Care management is best defined as a comprehensive suite of services and activities that are patient-centered to assist patients and caregivers in controlling complex and chronic conditions to better manage their own health. These programs focus on patient engagement, care coordination, and education to reduce hospitalizations, emergency department visits and improve the total cost of care.

To achieve the goals established for each individual patient, key components of care management must be in place. These include:

• A dedicated care team
• A comprehensive care plan
• Medication and care-management tools
• An inpatient facility-to-home program (also known as transitions of care or TOC)
• Patient education materials
• Expanded communication between patients, caregivers, and healthcare professionals.
• Care coordination with community and home-based service providers.

Types of Care Management

Disease Management
It is important not to confuse Disease Management with Care Management. Disease management is focused on the medical conditions and assists with education and specialty care around the defined clinical problems. While looking at a specific condition. Disease Management typically does not consider the patient’s co-morbidities, social determinants or Health Related Social Needs that may be impacting their primary condition or their ability to get the care needed. Disease Management programs are not considered patient-centric, but more disease centered and are heavily focused on providing education and not care coordination or engagement.

While it is not unusual for organizations to utilize both Disease Management and Care Management programs, Disease Management is typically involved in the initial stages of the patient’s condition to provide an educational basis for what is going on with their health and what to expect in the future. In addition, treatment options as well as preventive services can be used to reduce, delay, or prevent complications or sequelae from developing are discussed in detail.

In addition to medical treatments, Disease Management programs can stress the need for patients to take an active role in their health. Examples include avoiding environments where people are smoking when you have asthma, or the need to understand the importance of weight management and exercise when faced with new onset of diabetes.

Disease Management can be a great asset to Care Management in that it provides a basis of education for patients so that they understand their condition in general and can ask key questions of their assigned Care Manager to help the team gain insights into what may be needed to help the patient better control their condition.

Calculating the return on investment is not easy in this case. There is little evidence that Disease Management alone is enough to reduce the total cost of care. It does, however, play a role in patient satisfaction and provides a better understanding of a patient’s health problems. This results in improved patient satisfaction with the Care Management program and allows better participation by the patient in their own decision-making process.

Transition of Care
The typical place to start a Care Management program is with those patients who are being discharged from an acute inpatient setting to home by managing those patients transitioning from the acute care hospital setting to a home situation to reduce preventable hospital readmissions. By doing this, data has demonstrated improved patient outcomes as well as a reduction in cost of care for these patients in both the short and long term.

The success of these programs has been demonstrated as far back as 2008 and requires a focus on getting the resources and items in place that allow patients to continue their recuperation in their own home safely. Making certain that medical supplies, durable medical equipment, medication, and follow up visits are arranged is the key to prevention of more complex and costly medical problems. Transportation to and from appointments, meals, assistance at home with activities of daily living (ADLs) for patients and family also help reduce burdens on caregivers. Assisting in other areas, such as financial arrangements, housing, and providing counseling resources for both the patient and caregivers when needed, can go a long way to developing a relationship as a trusted source. Helping the member understand what might be expected, and developing a trusted relationship with their care manager, along with educating the member when something is wrong, and they should consider contacting their physician can help prevent unnecessary Emergency Department visits and readmissions. Most often, this is a limited engagement, usually less than 30 days (depending on the case management program). After that, the patients are either discharged from Care Management or referred to another level within the program.

The return on the investment here is easy to calculate and has been widely demonstrated. A reduction in the readmission rate and the number of Emergency Department visits is the best way to assess the value of the program and how well it is working.

Complex Care Management
This area of care is the most intense aspect of a Care Management program. Patients who would qualify for this program include the following:

• Two or more chronic conditions.
• A chronic condition that requires careful monitoring due to instability or is progressing.
• A physical health issue with either an overlying or underlying behavioral health condition.
• A significant behavioral health issue or substance use disorder.
• A patient from a post-acute program who requires ongoing care.

Providing a program tailored to the needs of each individual is the hallmark of this member-focused process. In addition, assisting the member in understanding their condition, working with them to educate both the member and caregivers, giving insights regarding helpful hints and suggestions as to the best way to deal with possible new issues and avoid sequelae of chronic disease, or overcoming barriers to getting care at the right time.
The team working through the program typically includes a nurse, a social worker, and a community health worker. Together, the team can provide assistance for the patient in dealing with social determinants of health which would include a safe place to live, overcoming financial hardships, dealing with problems in getting the right kind and amount of food needed, as well as identifying resources for mental health care and transportation. When you can provide someone who identifies with the patient and knows the community well, it creates a sense of trust and understanding that goes well beyond the principles of a solid program and makes for an even bigger success.

There are key components to a successful Complex Care Management Program. These include:

• Prioritizing Patients: There are many ways to identify patients who would benefit from a Complex Care Management Program, but because resources are limited, how do you decide who to manage first? Care management software utilizing algorithms or Artificial Intelligence can help in identifying patients who are at risk of a hospital admission, ED visit or an expensive procedure.
• Patient Engagement: Being able to find a patient, have the correct contact information, call, and talk to a patient can be the biggest challenge in a Care Management program. It is well known that health plans only are able to reach between 25-30% of patients that qualify for Care Management because contact information is not aways available or correct. Physician staff members, hospitals and other care providers have a much better success rate in both reaching patients and engaging them enough to convince them to take the next steps in getting involved with care managers. Working with both the patients and their caregiver is key to this success.
• Patient Enrollment: Once the patient is engaged, they need to be enrolled in the program. A care management platform is key to completing enrollment questionnaires and determining services that might be needed.
• Care Plan: Developing a Care Plan that meets regulatory requirements (State, Federal and certifying agencies such as the National Committee for Quality Assurance (NCQA) all have standards that must be met to get the Care Management program approved). The typical Care Plan template includes key components required to oversee the patient’s health, medical and social needs. These include:
  • Complete list of medical conditions
  • Medication list and allergies
  • Preventive care completed to date.
  • Environmental assessment, including threats and dangers to safety.
  • Achievable goals for each chronic condition identified as well as coordination of care or that condition and any planned interventions.
  • Identification of the care team involved with the patient.
  • Any care management activities or tasks planned by the team and the amount of time spent with the patient.
• Patient Visits/Telephonc Engagements and Documentation of Progress: Each outreach to the patient must be documented in the appropriate format. Any new situations or changes in the patient’s condition must be clearly documented as well as any changes or progress toward goals.
• Quality Metrics: A focus on fulfilling key quality measures as defined in STARS, HEDIS or by the certifying agency is paramount. Ensuring that patients engage with their doctors and get the preventive care they need or control their chronic conditions by taking medications on time and getting lab studies is key to preventing long-term complications and progression of chronic conditions such as diabetes or hypertension. Earning compensation for meeting quality measure targets is also a key component for Complex Care Management programs and can be used to measure the success of the program.

Measures used to monitor Complex Care Management programs are both process and outcome oriented. These include:

• Outreach metrics, including patients identified and outbound calls to patients, as well as both successful and unsuccessful engagements.
• Enrollment metrics
• Care Plan completions.
• Ongoing care outreach
• Quality measures and completion to target
• Outcome data
  • This is the most difficult to ascertain and can be done in several ways including:
    • Patient satisfaction
    • Reduction in ED visits (when compared to a propensity-matched control group)
    • Reduction in hospital admissions or readmissions (when compared to a propensity-matched control group)
    • Total cost of care for those enrolled in a program versus those not enrolled (when compared to a propensity-matched control group)

Staffing
Care management staffing can differ by program and by state. Best practices include:

Care management programs – which can include.

• Special Needs Plans:
  • Chronic Condition Special Needs Plans (C-SNP) – such as HIV/AIDs, Diabetes, Cardiovascular disease.
  • Dual Eligible Special Needs Plans (DSNP) –eligible for both Medicare and Medicaid
    • Highly Integrated Dual Eligible Special Needs Plan (HIDE-SNP): D-SNP plan with increased Medicaid integration
    • Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): The most integrated Medicaid D-SNP
  • Institutional Special Needs Plan (I-SNP) – live in a long-term care setting either in the facility or in the community needing nursing home level of care.

Care Manager Roles
Ideally, care managers are clinically licensed professions with a minimum of a bachelor’s degree in a related field. Care managers are usually nurses or social service professionals who deliver care management interventions either in person or by phone.

Caseload
The caseload ratio varies based on the level of care needed. A care manager’s caseload can range from 25 to 250, depending on the care management program being used. The best practice is no more than 75 patients per care manager.

Staffing Strategies
Staffing varies based on care management program and patient acuity level. Staffing strategies should include:

• Technology – drives growth and can help with recruitment.
• Incorporate Telehealth –enhances patient care, improves outcomes, and addresses staffing deficiencies.
• Implementation of flexible staffing models – should be based on evidence-based practice, including better employee benefits.
• Staff buy-in – Engage staff to increase productivity and motivation, which can lead to improved outcomes.
• Professional networking – creating a network of case managers and healthcare professionals to provide mentoring, support, and partnerships.

Choosing a Care Management Platform
COPE Health Solutions is uniquely positioned to support the enhancement of your Population Health management capabilities through proven, flexible tools that can be configured to current and future business needs. ARC offers a comprehensive enterprise data management system that provides Clinical and Financial Insights, Provider and Specialty performances, VBC Analytics among other tools. COPE Health Solutions also provides experts to assist you with meeting your goals.

Request a demo today! Learn more about COPE Health Solutions at https://copehealthsolutions.com/.