Care Management 101: How Software Can Reduce Costs & Improve Outcomes

A patient-centered experience. Better health outcomes. A lower total cost of care. This trifecta is the ultimate goal for health systems, providers, and payers of all sizes.

Over the past decade, care management (CM) has emerged as the leading strategy for driving healthcare delivery transformation and maximizing population health management efforts. But what is it, exactly? And how can CM software empower teams to deliver better, more efficient, whole-person health care?

Ahead, we explore how CM brings the patient to the center of care in order to reduce health risks and decrease the cost of care.

What Is Care Management?

Based on client experience, McKinsey defines care management as “any payer-driven efforts to engage with targeted members and their care ecosystems to encourage and enable high-value decisions around their care and improve self-management.” This includes complex case management, acute care, transition of care, and condition management – all with engagement through phone, in-person interactions, online meetings, and automated reminders.

For many payers and providers, the “targeted members” are patients with chronic diseases or complex conditions; however, those with particular risk factors or social determinants of health (SDOH) may also be included. More advanced CM programs match the level of care management to the needs of a targeted population.

High-risk or high-need members with chronic conditions and high medical spend (e.g., extensive ED visits or inpatient stays) may warrant a larger care team and/or more complex care management. Low-needs members who tend to prioritize routine and preventative care may only need digital engagement with occasional escalation to a care team. The ability to customize engagement according to member needs helps CM programs run efficiently while maximizing ROI.

In order to effectively reduce hospital visits and improve member health, CM requires the careful coordination of everyone involved in managing patients: physicians, primary care providers, post-acute clinicians, behavioral health providers, patients, and their families or caregivers.

Essential Elements of Care Management

While CM programs can vary greatly, there are a few must-haves that help ensure success.

• Dedicated care team members, including a specially trained care manager: Each member of the team should have a different, well-defined role. The care team regularly communicates about a patient’s treatments, assessments, interventions, and overall care plan.
• A variety of engagement methods: In-person encounters, such as home visits and a hospital-to-home program, are critical to appropriately diagnose, treat, and support the ongoing health needs of patients with chronic conditions. Digital, mail, and phone check-ins are a cost-efficient way to close gaps in care between in-person engagement. Leveraging multiple channels to reach members, with microtargeting and personalization, increases the likelihood that members will take an active role in their health journey.
• Education and patient or caregiver coaching: Providing patients and caregivers with tools and information can help them better manage chronic conditions at home and recognize signs of worsening disease. From tracking logs and how-to videos to portal newsletters and reminder texts, there are numerous ways to help members help themselves.
• Access to medication, transportation, and appointment scheduling: CM goes beyond simply recognizing members’ needs. An effective CM program enables better health care delivery, whether that involves scheduling appointments, arranging transportation, or automatically refilling medications for delivery.
• A 360° member view: Beyond clinical data and healthcare records, CM takes into account the entire person. That’s because research has shown that non-clinical factors (such as economic stability, education, and social context) can determine up to 80% of a person’s health. Social determinants, non-clinical risk factors, and the integration of community resources are all key aspects of CM.

The Role of Care Management Software

Care management software solutions can greatly streamline core CM processes, so the team can focus on patient care, rather than manual coordination, paperwork, and reporting. At a basic level, CM software provides a set of tools and features that digitize and automate tasks like care plan development, appointment scheduling, and report generation.

At a more advanced level, a CM platform applies artificial intelligence (AI) and integrates with Utilization Management (UM) in order to make CM even more intuitive, connected, and efficient. This allows providers to maximize both member engagement and the overall value of their CM programs.

Care Management Software in Action

As an example, let’s explore a patient scenario where CM software improved outcomes and lowered the total cost of care.

1. John went to the ER with a high fever and a cough.
2. He was admitted and treated for pneumonia.
3. During discharge, a follow-up appointment was automatically scheduled.
4. Reminders were sent via his preferred channels of communication, and confirmations were received.
5. However, John still missed his follow-up appointment.
6. The care manager was alerted and reached out to remedy the situation. She noticed that transportation had been an issue in the past, and offered to schedule a ride.
7. John went to his follow-up. His physician noticed a complication and prescribed medication to treat it. If left untreated, it could have landed him back in the ER.
8. During the appointment, his physician also noted that John had lost weight since the start of his illness. John said that money was tight since he had been out sick and unable to work.
9. The care manager followed up with John with information on nearby food banks and a step-by-step guide on how to apply for temporary assistance.

With the help of a CM platform, John received personalized care and had a better outcome. The CM solution automated appointment scheduling identified John’s transportation risk and flagged his missed appointment. This level of automation and intelligence allows providers to focus on offering the highest quality care, instead of on paperwork and administrative tasks.

From enrollment and referral to care plan development and beyond, the right CM software offers care managers and teams a way to efficiently manage member health in a few clicks. If you want to learn how VirtualHealth is automating CM workflows and tasks in order to help improve member health, reduce duplicate or unnecessary services, and enhance care coordination and the quality of care, check out our care management solution.