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Best Practices for Your Care Management Process

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The transition to value-based care has hospitals exploring new avenues to cut down on preventable costs, such as readmissions, duplicate lab and imaging studies, and unnecessary treatments and procedures. One way providers are tackling such preventable costs is through expanding care management programs and focusing on improving their effectiveness.

The Center for Health Care Strategies, Inc. (CHCS) established that “…the goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.”1 This can involve diverting patients away from the emergency room and towards more appropriate care settings, such as urgent care centers and primary care physicians. Such settings provide greater care continuity, access to resources, such as behavioral health experts, pharmacists, and nutritionists, and can more effectively address various health factors.

Care management programs take a unique approach to reducing the cost of care focusing on improving the overall health of patients by meeting their unique needs, with the objective of reducing unnecessary or duplicative  and often costly medical services.. Care management programs have great potential to improve overall population health and bridge communications amongst multiple specialists. Providers need to make sure that their care management processes adhere to  the best practices below to ensure the most positive — and cost-effective — patient outcomes. 

Here are four steps that should be a high priority when designing your care management process.

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1. Create and follow care plans

Care plans detail medical needs, histories, patient goals and interventions so that disparate caregivers provide consistent treatment and assistance. Patients need to be risk stratified to ensure optimal use of care management resources. More complicated patients such as those with COPD, hypertension and diabetes, taking several medications should receive greater, and more urgent, attention. When hospitalized, these high-risk patients require extensive care planning before discharge. Such efforts may include performing a comprehensive medication review, securing reliable transportation, and ensuring access to the appropriate durable medical equipment at home. It also includes assistance with coordinating a timely post-discharge follow-up with the patient’s PCP, a vital component of ensuring an effective care plan. Care managers should maintain care plans to ensure that patients with complex health needs have the resources and support necessary to receive the best care possible.

2. Assign patients to primary care managers

A primary care manager, often working in collaboration with a PCP, can provide a sense of familiarity and consistency to everyone involved in a patient's care continuum, from providers to patients and their families. Designating a primary care manager as a point of contact helps create optimal conditions for patients to follow their care plans and support patient-centered care management. This individual can access information such as labs, discharge summaries, medication lists, and x-rays, and ensure they’re available to the clinical team to take appropriate action. Perhaps more important than the coordination activities,  the  personal relationship that the primary care manager forges with the patient enables them to impact care in ways that time-constrained primary care physicians and specialists cannot. Encourage primary care managers to build trust, to help patients be more effectively engaged in their treatment, which should help yield stronger  treatment plan adherence.

3. Account for psychosocial factors

Care managers must consider far more than comorbidities, medication management, and follow-up appointments. If care managers do not take patients' psychosocial situations into account, less fortunate patients may experience inferior outcomes. Some patients struggle with difficult situations and decisions, such as choosing between covering a copay and buying a meal, or taking care of tasks at home versus picking up a prescription.

Partnering with social workers helps address many of these barriers, as does gaining a better understanding of patients’ home lives. Recognizing that personal factors, including one’s financial situation, support system, nutritional habits, and cultural background, are as important as physical conditions is critical in providing patients with the care they need.

4. Rely upon motivational interviewing techniques

The use of motivational interviewing represents another way providers can shift care from physician-centered to patient-centered. It’s a way of speaking with patients rather than at them. Exploratory questions encourage patients to develop their own understanding of their care and gain self-efficacy while optimizing care managers’ work by approaching their patients as individuals rather than accounts or medical charts. Empathetic methods of meeting patients in their comfort zones helps create a more nurturing, less combative conversation surrounding sensitive topics such as medication adherence. Whether through the linking of a major life event to following a care plan or allowing the patient to take the lead in identifying solutions to their problems, give patients ownership of their care thus turning care management into a more collaborative process.

Fortunately for care managers there are resources available to help them best serve patients. For example, advancements in predictive analytics are more effectively identifying high-risk populations upon which care managers can better focus their efforts.

Whether facilitating transitioning between providers or improving medication adherence, drilling down to the individual level and focusing upon their unique needs is one of the most effective ways to serve patients.

Their backgrounds, personal situations, struggles, and goals are all factors just as integral to care management as symptoms and medications. Tying all this together under one primary care manager helps create a solid foundation for close relationships that foster understanding, trust, and communication.

For patient populations without formal, end-to-end care teams in place to handle their treatment, closely examine the needs of those populations and take steps to help reduce their health risks while encouraging them to take more active roles in their care.

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