How HELIOS Addresses the CMSA Standards for Case Management

The Case Management Society of America (CMSA) outlines eighteen standards for the foundation of a case manager’s responsibilities. The HELIOS care management platform is designed to empower case managers to create better outcomes for their clients. Learn how HELIOS enables professional case managers to perform the Standards of Practice for Case Management, as outlined by the CMSA. Different terms are used to identify people who are receiving care. At VirtualHealth, we most often refer to them as members and will do so here.

1. Member Benefit Determination

CMSA Standard of Practice
Consider predictive modeling, screening, and other data, where appropriate, in deciding whether a member would benefit from case management services.
How HELIOS Empowers Case Managers

Case management has the power to create healthier populations, but resources are limited. HELIOS automatically identifies patients who can benefit from case management through built-in analytics for HCC, CDPS, and HEDIS and with proprietary HRS- and HRA-based risk algorithms.

Risk scores are updated in real time and are displayed on a dedicated, configurable view that can be filtered and searched.

2. Assessments and Case Management Plans

CMSA Standard of Practice
Conduct an assessment of the member’s health, physical, functional, behavioral, psychological, and social needs, including health literacy status and deficits, self-management abilities and engagement in taking care of own health, availability of psychosocial support systems including family caregivers, and socioeconomic background. The assessment leads to the development and implementation of a member-specific case management plan of care in collaboration with the member and family or family caregiver, and other essential healthcare professionals.
How HELIOS Empowers Case Managers

Every person is unique and requires a tailored approach that goes beyond clinical care. HELIOS provides configurable, comprehensive assessments that consider clinical, mental, and environmental aspects of health as well as a member’s network of support. Responses on assessments automatically trigger fields in the care plan with mapped problems targeting interventions and customizable goals.

Case managers can personalize care plans to reflect specific care goals, interventions, target dates, and barriers, while monitoring progress for each health or social need. HELIOS can automatically populate problems from relevant medical history based on business rules or clinical guidelines.

HELIOS effectively supports collaborative care plan creation and sharing with the member, caregivers, providers, and any other appropriate parties.

3. Care Goals Identification

CMSA Standard of Practice
Identify target care goals in collaboration with the member, member’s family or family caregiver, and other members of the care team. Securing member’s agreement on the target goals and desired outcomes.
How HELIOS Empowers Case Managers
Collaborative care plans allow case managers to work with the member and their caregivers to identify target care goals. Electronic signatures give members an opportunity to agree to the target goals and the desired outcomes. Offline and remote access allows case managers to obtain the member’s agreement no matter where they are.

4. Intervention Planning

CMSA Standard of Practice
Plan the care interventions and needed resources with the member, family or family caregiver, the primary care provider, other healthcare professionals, the payer, and the community-based agents, to maximize the member’s care responses, quality, safety, cost-effective outcomes, and optimal care experience.
How HELIOS Empowers Case Managers

Better outcomes require a proactive ecosystem of care seamlessly working together around the member. This ecosystem is guided by a high-functioning care plan. HELIOS enables case managers to work with the member and the care team to create a care plan tailored to the member’s holistic needs. The platform supports multiple care plan templates and enables administrative users to configure goals, interventions, barriers, progress terms, and statuses. Case managers can use templated terms or enter their own goals, interventions, and barriers.

When a case manager selects a clinical or behavioral health need, intelligent workflows adjust the options for care goals, interventions, activities, barriers, and progress metrics. Case managers can also manually modify the need associated with an option.

Case managers can work with the entire care team to utilize a robust suite of third-party and integrated resources directly through HELIOS to ensure that the member’s healthcare experience is maximized.

5. Care Team Coordination

CMSA Standard of Practice
Facilitate communication and coordination among members of the interprofessional care team, and involving the member in the decision-making process in order to minimize fragmentation in the services provided and prevent the risk for unsafe care and suboptimal outcomes.
How HELIOS Empowers Case Managers

Communication among the interdisciplinary care team is key when it comes to keeping members as healthy as possible. HELIOS seamlessly incorporates all members of the care continuum into its ecosystem including members, their families, providers, the interprofessional care team, and other care specialists to promote optimal care.

Users can leverage a wide array of collaboration and communication tools to enable coordination among members of the interprofessional care team – including the ability to route from one user to the next and to prevent a case closure until all of the required inputs have been validated. These communication tools and configurable workflows, coupled with interoperability functionalities, enable staff to support safe and optimal care transitions.

Secure messaging allows care team members to easily communicate with any member of the care team and the member.

6. Provider Collaboration

CMSA Standard of Practice
Collaborate with other healthcare professionals and support service providers across care settings, levels of care, and professional disciplines, with special attention to safe transitions of care.
How HELIOS Empowers Case Managers

Improper care transitions can lead to adverse events, including higher hospital readmission rates and costs. It is imperative that a solution has simple collaboration tools that allow the healthcare professionals to work together and mitigate the risk of ineffective transitions.

VirtualHealth integrates with third party vendors, such as MCG, that provide transition and discharge criteria. These criteria are embedded in configurable workflows and set triggers and alerts notifying the care team of the next best action.

The entire care team can access the HELIOS ecosystem through role-based access, which includes care providers and third-party services. Administrators can configure the level of information that team members can see.

Through an HIE integration, HELIOS can automatically identify member discharges. This helps case managers focus, prioritize, and provide timely transitional care, support, and follow-up.

7. Resources Coordination

CMSA Standard of Practice
Coordinate care interventions, referrals to specialty providers and community-based support services, consults, and resources across involved health providers and care settings.
How HELIOS Empowers Case Managers

To make integrated care successful, the process needs to be seamless. VirtualHealth works extensively with city, county, and state health and human services agencies. HELIOS features the most robust capabilities for integrating local community resources, such as transportation, in the industry.

VirtualHealth can incorporate providers and third-party service agencies into the HELIOS ecosystem and provide role-based access, whether through a dedicated portal or a dedicated view. This allows everyone to avoid the friction of working cross-functionally and across industries.

8. Member Communication

CMSA Standard of Practice
Communicate on an ongoing basis with the member, member’s family or family caregiver, other involved healthcare professionals and support service providers, and assure that all are well-informed and current on the case management plan of care and services.
How HELIOS Empowers Case Managers
Patients engaged in their care show higher rates of better outcomes. HELIOS provides the member and the member’s caregiver with dedicated portals and a member-friendly mobile application through which case managers can upload, share, and view educational materials. The care team can use either of these for secure messaging, data exchange, and viewing care plans.

9. Member and Care Team Education

CMSA Standard of Practice
Educate the member, the family or family caregiver, and members of the interprofessional care team about treatment options
How HELIOS Empowers Case Managers

To fully engage members, they must be made aware of their treatment options, the services available to them, and potential barriers which they may not be expecting.

Users from any part of the care team within the HELIOS ecosystem can share educational materials, alert members of treatment options, and make them aware of as well as order community resources. That means care teams can efficiently coordinate internal and external resources to meet the unique needs of members and empower informed healthcare decisions for members and their families.

10. Member Counseling

CMSA Standard of Practice
Counsel and empower the member to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.
How HELIOS Empowers Case Managers
VirtualHealth’s native health and wellness functionality can support health coaching and counseling through tools for sharing educational materials, configurable member-facing forms and surveys, built-in messaging, and telehealth support.

11. Utilization Management and Reviews

CMSA Standard of Practice
Complete indicated notifications for and pre-authorizations of services, medical necessity reviews, and concurrent or retrospective communications, based on payer’s requirements and utilization management procedures.
How HELIOS Empowers Case Managers

HELIOS supports the full Utilization Management workflow, from the authorization request to the auto-approval rules, medical necessity reviews, disposition, and correspondence.

The workflow can be tailored to allow providers and care team members to submit prior authorization requests using a customizable form that can:

  • incorporate specific guidelines;
  • route those requests to the appropriate department;
  • capture requests for more information;
  • conduct auto-approvals or auto-pends;
  • support and track clinical review;
  • record the final determination;
  • communicate the determination to the provider and member by auto-populating configurable correspondence templates.

The platform is capable of automating level of care guidelines with products such as MCG or InterQual. Data from these systems auto-populates the corresponding components of the VirtualHealth workflow.

In addition, HELIOS provides collaboration, communication, and reporting tools that may be used to conduct concurrent and retrospective utilization reviews. The workflow automatically routes tasks, ensuring that the entire care team can properly monitor any prior authorization requests.

HELIOS provides highly customizable Utilization Management functionality including the ability to incorporate custom service types, categories, and descriptions. This is particularly important because UM processes tend to be highly organization-specific and dependent on regional regulatory standards.

Finally, HELIOS enables full integration between care management and utilization management functions, with UM events such as Authorization Statuses generating CM follow-up tasks.

12. Appropriate Allocation and Usage

CMSA Standard of Practice
Ensure the appropriate allocation, use, and coordination of healthcare services and resources while striving to improve safety and quality of care, and maintain cost effectiveness on a case-by-case basis.
How HELIOS Empowers Case Managers

VirtualHealth’s mission is to build value-added technology that automates and optimizes healthcare delivery, improving outcomes while reducing costs. The company’s foundation is an unwavering commitment to supporting members and providing the best technology and an unparalleled level of service.

HELIOS users can configure guided clinical decision pathways to ensure that the member receives the right services, at the right time, and at the appropriate care setting.

13. Barriers to Care Identification

CMSA Standard of Practice
Identify barriers to care and member’s engagement in own health; address these barriers to prevent suboptimal care outcomes.
How HELIOS Empowers Case Managers

Member engagement is a determining factor for better outcomes. VirtualHealth believes that healthcare needs to be more centered on its members and strives to empower members to participate in their care.

The customizable assessments in HELIOS appropriately identify and address member needs and any barriers to their care. HELIOS then gives case managers the tools to assist members through a wide-ranging suite of services that are accessible directly through the platform. These include meal delivery, transportation, and home health aides.

14. Transitions of Care Enablement

CMSA Standard of Practice
Assist the member in the safe transitioning of care to the next most appropriate level, setting, and/or provider.
How HELIOS Empowers Case Managers
HELIOS aims to provide the care team with the right information to identify the most appropriate setting of care for members and to improve care transitions between those settings. Care coordination workflows identify optimal settings of care for members and notify the care team through automated tasking and alerting. These workflows reduce the rates of inappropriate hospital admissions and unnecessary emergency department visits by providing care coordinators with all relevant information to increase productivity and efficiency and streamlining post-discharge follow-up through intuitive assessments and automated care plan updates.

15. Member Independence

CMSA Standard of Practice
Strive to promote member self-advocacy, independence, and self-determination, and the provision of member-centered and culturally-appropriate care.
How HELIOS Empowers Case Managers
HELIOS builds a 360° view of its members, ensuring that the care team has a robust understanding of their populations. Members are able to access HELIOS through a dedicated portal in which they can engage with their care team, request resources, gain insight into their care, and participate in rewards programs. By providing a suite of intuitive member tools, HELIOS centers care around the members and promotes member self-advocacy.

16. Member and Organization Advocacy

CMSA Standard of Practice
Advocate for both the member and the payer to facilitate positive outcomes for the member, the interprofessional care team, and the payer. However, when a conflict arises, the needs of the member must be the number one priority.
How HELIOS Empowers Case Managers
Member needs should always be top priority in healthcare. HELIOS is designed to create better outcomes for its members by creating a seamless ecosystem encapsulating all aspects of a member’s care. Member needs are always top priority, with best-in-class workflows and business rules that trigger key activities to optimize outcomes for all parties involved in caring for the member.

17. Outcome Measures Application Evaluation

CMSA Standard of Practice
Evaluate the value and effectiveness of case management plans of care, resource allocation, and service provision while applying outcomes measures reflective of organizational policies and expectations, accreditation standards, and regulatory requirements.
How HELIOS Empowers Case Managers

Organizations leverage HELIOS to improve member outcomes while increasing productivity and lowering costs. It is imperative that they be able to track these measures and understand how they can optimize their processes. HELIOS logs and time stamps every action. Users have access to their own activity logs and administrative users have access to the logs of other users.

The platform tracks all activity through a set of searchable longitudinal case notes, through specific interaction tracking tools, and through reports. Reports can track care team efficiency and appropriate resource allocation. Customized reports include productivity reports, caseload reports, status reports, and monitoring reports. These reports can be presented in the form of line charts, pie charts, and bar graphs, where applicable.

18. Performance Improvement

CMSA Standard of Practice
Engage in performance improvement activities with the goal of improving member’s access to timely care and services, and enhancing the achievement of target goals and desired outcomes.
How HELIOS Empowers Case Managers
VirtualHealth is committed to actively assisting clients in solving their greatest challenges and creating solutions that are moving them forward. We take a consultative approach to our partners' challenges, helping them meet their targeted goals and desired outcomes so that they can provide the highest level of care to their members.