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
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 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
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
4. Intervention Planning
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
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
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
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
9. Member and Care Team Education
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
11. Utilization Management and Reviews
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
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
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
15. Member Independence
16. Member and Organization Advocacy
17. Outcome Measures Application Evaluation
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.