Integrated care is a key focus of next-generation care management programs, relying on clinical, social and behavioral data to paint a complete picture of a member and pinpoint where care gaps and barriers exist. Analytic technologies use this data to identify members who are most impactable and intervenable, while digital technologies enable personalized approaches to outreach and care coordination.
The result is being able to engage in the right way with the right members and drive high-value improvements in clinical and financial outcomes. However, many healthcare and insurance providers struggle with finding a single platform that integrates the analytics and technologies required to achieve these transformational results.
Bringing value to care management
In the changing healthcare environment, care management is a key strategy to reduce costs, improve quality of care and enhance patient experience. To best optimize care management, a platform that unites integrated analytics and digital technology is key, including:
- Using analytics to identify at-risk members who are most willing and able to engage
- Creating a 360-degree member profile to identify medical, behavioral and social needs
- Incorporating digital innovations to automate manual workflows and tasks
- Delivering automated omnichannel communication to meet member needs and preferences
The value-based market is all about a new care ecosystem, characterized by new models of care delivery that are member-centric and foster accountability for member outcomes and care effectiveness. We know the goals of this new value-based ecosystem are to improve effectiveness and quality of care (including addressing health equity and reducing disparities of care), reducing overall cost of care and improving the experience of care.
"It's really all about creating accountability for organizations to achieve improvements in these care outcomes," says Mary Beth Newman, Senior Assistant Vice President, Clinical Products at EXL Health. "So it makes sense that the key success factors for this new value-based ecosystem include a coordinated and integrated population health model, effective processes for member identification, engagement, and care coordination, and integration of technology for advanced analytics, data integration and reporting."
So what helps drive this value equation? Consider the abundant evidence of outcomes that an integrated care management program includes, like:
- Reducing inpatient volume and unnecessary ER utilization
- Improving access to evidence-based care
- Positively impacting HEDIS/STARS results
- Improving member and population outcomes – health, quality of life, satisfaction
Best practices in care management
In general, best practices can be used to gauge the maturity level of any given organization's clinical operations and fall into two categories — operations and technology. The more best practices in place, the more value will be derived.
"There's definitely a cumulative effect that happens—mastering one or two key best practices often paves the way for others to fall into place," says Newman.
Some of the key best practices in operations focus around:
- Alignment with professional standards of practice and an individualized approach
- Evidence-informed programs and services with an emphasis on SDOH impacts and barriers and care gap management
- Leveraging community resources, providers and care teams to meet member needs and to ensure staff operate at the top of their license
- A culture of continuous quality improvement in the population health management framework
Some of the key best practices in technology center on:
- Identifying subpopulations for targeted interventions and predictive modeling that identify the most impactable members
- Integration of SDOH data into risk identification
- Decision enabling dashboards and reporting using a single integrated care management platform to drive actions and outcomes
- Personalized engagement with integrated telehealth, online portals and remote monitoring with individualized data
Advantages of an integrated approach
One of the biggest advantages of having an integrated approach to create an effective care management ecosystem is that organizations can use the power of data, automation and AI to not only to focus on the right members with biggest impact, but also to improve efficiencies.
"A true member centric approach starts with integrating all the information, extracting intelligence from it and putting in the hands of stakeholders like care managers so they can operate on top of their license," says Smita Sawant, Vice President of Data and Analytics, EXL Health. "With analytics, organizations can introduce a multi-layer approach that focuses on members who are high risk in near term or emerging risk, but also overlay the members who you can really impact right away."
This kind of impact can translate into outcomes all organizations are looking for – hospital admission reduction, ED reduction, readmission reduction – but it all comes together using a single integrated care management platform, with a key factor of prioritizing members and their interventions.