But despite many dedicating 10% or more of their administrative spend on care management programs,1 ensuring members receive the right care at the right time – which is the essence of effective care management – is more challenging than ever.
Today, the average care manager can be responsible for up to 200 members each month, depending on the setting. In addition to high caseloads, the traditional 30+ day lag in claims data is not timely enough to effectively coordinate care when it’s needed most.
To accomplish the task of both improving quality metrics and reducing costs, payers are taking a more active role in care delivery than ever before. But truly maximizing the return on your case management investment requires a better, more timely flow of member data between payers and providers.
That’s where care management notifications can help. By immediately notifying payers of clinical events that require timely follow up, this easy-to-implement solution equips case managers with the information needed to reduce costly care gaps, increase quality scores, and optimize financial performance.
Prioritizing Care Management for Improved Outcomes
The premise of care management notifications is simple: Leverage technology to monitor care so scarce payer resources can be deployed where they matter most.
This is accomplished by prioritizing follow-up aftercare events that are likely to have the biggest impact on member outcomes – including hospital admission, discharge, and transfer (ADT) events. Care management notifications prioritize ADT events because the intervention of a care manager or case manager during these critical windows of time can play a crucial role in avoiding poor health outcomes.
With access to timely, actionable member data, payers can prioritize case management resources to improve plan quality performance as measured by State and Federal programs such as NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) and CMS’ Medicare Star Ratings. The result: better patient outcomes, higher satisfaction scores, and greater cost savings.
Here’s an example: Jenny is a 66-year-old Medicare patient who has been diagnosed with congestive heart failure (CHF). Although CHF is a chronic condition, her primary care physician (PCP) has prescribed multiple medications to help her manage the symptoms.
During vacation, Jenny ate a lot of high-sodium food and forgot to take some of her medications. Upon returning home, she experienced swelling in her legs and shortness of breath. Since it was a Saturday, she went to the local Emergency Department for treatment.
The hospital admitted Jenny for treatment. But upon discharge, she didn’t receive timely follow-up from her PCP or have a case manager assigned to her. Once at home, she was confused about the medications she was prescribed at the hospital and didn’t realize they might conflict with the prescriptions she had at home.
A few days later, Jenny was admitted to the ED again after she began feeling light-headed and short of breath. Without the appropriate care team involvement, she was readmitted to the hospital and suffered an adverse drug event leading to higher costs and a longer length of stay – circumstances which could have been avoided with care management notifications.
Not only did Jenny’s health suffer, but this lack of care coordination negatively impacted her health plan’s quality measures, including Hospitalization for Potentially Preventable Complications (HPC), Plan All-Cause Readmissions (PCR), and Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC).
Leveraging Notifications to Change the Trajectory of Care
How do care management notifications work? First, member-provider relationships are configured in the notification system. Then, when an ADT event is recorded (e.g. a visit to the emergency room), that member’s care team, including the payer’s case manager, is notified in real time.
Using this timely, actionable information, case managers can follow up with the member at just the right moment – improving care coordination while reducing unnecessary hospital readmissions.
In organizations where ADT alerts or notifications have been implemented, payers have witnessed firsthand the impact this timely information can have – and how it can change the trajectory of a member’s care.
Here are a few examples:
- Hospital admissions: To ensure providers are delivering the best care possible, payers need to know when one of their members experiences a sudden injury or illness. But all too often, delays in claims data mean they can be one of the last to learn that a member has visited the Emergency Department. Care management notifications alert payers when emergent care is provided – enabling timely follow-up to close care gaps and reduce readmissions. This information can be leveraged to improve compliance for measures which target 7-day and thirty-day follow-up rates such as Follow-Up After Emergency Department Visit for Mental Illness (FUM), Follow-Up After Emergency Department Visit for Substance Use (FUA), or Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC).
- Inpatient discharge: After an inpatient hospital stay, care management plays a critical role in improving health outcomes and reducing readmission rates. When a payer’s case manager is notified of a member discharge, they can proactively follow up to recommend care plans, medication reconciliations, and follow-up appointments – leading to lower Plan All-Cause Readmissions (PCR).
- Transitions of care: When a member transitions from an inpatient hospital to a post-acute setting, delays in sending patient information are common. Care management notifications equip both payers and rehabilitation providers with the data they need to inform a member’s care plan. For Healthfirst, a hospital-sponsored health plan in the greater New York City area, InterSystems care management notifications were used to generate a simple email reminder to providers following discharge, improving overall compliance with the Transitions of Care (TRC) Medication Reconciliation Post-Discharge measure by 5%.
- Wellness visits: Care management notifications can also be configured to remind Medicare members of overdue wellness visits, which can help identify early signs of serious health conditions like diabetes and congestive heart failure and get them treated before they lead to a hospitalization. This early intervention improves the likelihood that a member will schedule their recommended appointments – reducing the overall cost of care while bolstering HEDIS measures related to Prevention and Screening.
4 Benefits of Care Management Notifications
Care management notifications aren’t new to healthcare, but they are underutilized across many payer organizations. By implementing a system like the InterSystems HealthShare Care Management Notifications Solution Pack, payers can leverage real-time alerts to:
- Improve health outcomes: By monitoring a member’s health over time, case managers can quickly reach out after trigger events such as hospitalizations. This proactive approach to care management improves member adherence to care plans, resulting in better health outcomes and higher quality scores.
- Reduce high-cost readmissions: When a primary care provider or case manager follows up with a member after discharge, it can reduce costly hospital readmissions by up to 50%.2
- Optimize financial performance: An increased adherence to recommended clinical guidelines, such as annual Medicare wellness exams, colonoscopies, and mammograms, leads to higher Medicare Star Ratings – which directly impact reimbursement rates.
- Lower costs: Proactive care management also reduces unnecessary costs incurred by duplicate testing and adverse drug events.
Make the Most of Limited Resources
Once implemented, care management notifications can help break down the communication barriers that exist between payers and providers. This enables greater collaboration – resulting in more coordinated delivery of the right care at the right time to the right members.
Let’s return to our earlier example of Jenny. With care management notifications, her PCP would have been notified of her admission to the hospital – prompting a review of her symptoms and treatment. Then, her payer’s case manager could reach out after discharge to explain her care plan, answer any questions related to medications, and discuss the importance of follow-up appointments. Jenny would have avoided a potentially dangerous adverse drug event. The hospital would have avoided a costly readmission penalty. And the payer would have eliminated the high cost of her readmission (not to mention the negative impact on quality measures).
Using care management notifications, everyone benefits. Members experience better health outcomes; providers and care managers deliver more efficient care; and payer organizations improve clinical and financial performance.
1. The untapped potential of payer care management | McKinsey. www.mckinsey.com. https://www.mckinsey.com/industries/healthcare/our-insights/the-untapped-potential-of-payer-care-management
2. Vernon D, Brown JE, Griffiths E, Nevill AM, Pinkney M. Reducing readmission rates through a discharge follow-up service. Future Healthc J. 2019;6(2):114-117. doi:10.7861/futurehosp.6-2-114
