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November 04 2019 | 0 Comments | 161 reads Average Rating: 4.3

Scaling Care Management Beyond the Highest Risk Members

by Jodi Siegel, MSHI, BSN, RN (Guest Author) in Health Analytics

With 5% of Americans accounting for 50% of the cost1 of healthcare, it’s easy to see why payers (and providers) tend to focus on those most in need of health intervention – the highest-risk members with multiple co-morbid conditions. They know if they can improve the health outcomes for those members, they can make an impact on the overall cost of care.

However, in healthcare, some of the best long-term opportunities for savings come not from reactively treating the highest-risk members but by preventing members from reaching that level in the first place. By segmenting populations into various risk buckets and creating varying levels of care and engagement strategies based on their levels of risk, health plans can keep a core focus on the most costly members today, but can also dedicate resources to mitigating future risk and costs.

The following outlines how our organization is tackling rising risk factors across the populations we serve and covers key best practices for taking a whole member approach to designing effective member care and engagement strategies.

Take a holistic, member-centric approach

The typical healthcare model leaves the navigation and coordination of all of a member’s care to the person with the least amount of knowledge about what care and resources are available: the member herself.

A strong care management program will assist the member in navigating through the total care experience, bringing in resources as-needed, including such resources as housing, transportation and specialists, to support the members in becoming or remaining as healthy as possible. It ensures they receive the right interventions from the right providers and at the appropriate level (high-, medium- or low-touch) while also working with members to improve their engagement in their own care.

Create multidisciplinary care teams

Another flaw in the current system is a tendency to look at each health issue on an individual basis rather than as part of the whole picture. Members could have many providers, each solving different health needs independent of each other.

A better approach is to create interdisciplinary teams centered around the member and “conducted” by an experienced nurse care management. The team may include a medical director, nurses, pharmacists, behavioral health specialists, dieticians, radiologists, social workers and non-clinical support staff members who meet regularly and work in a coordinated manner to address all of a member’s needs. This cross-pollination and collaboration creates a dynamic care team all aligned around the member and lending itself to the opportunity to share insights, experiences and expertise invaluable to driving better health outcomes.

Set up care management levels

Segmenting populations across varying levels of health statuses and risk is a great way to understand how to engage and intervene with members. From healthy members to at-risk members to early chronic and all the way to members with late-stage conditions or diseases, health plans can formulate care and engagement programs based on the unique needs of the segment. Predictive analytics allow health plans the ability to move down the pyramid and address populations who are likely to have increases in cost and utilization, versus those who already have complex conditions and are high-risk. Proactive care delivery and intervention can be provided to members in order mitigate future risk and costs.

For greater value, the combined use of predictive and prescriptive analytics can help to further prioritize and engage with members based on their level of impactability and Intervenability. By looking at a member or population’s impactability level, one can quickly identify where to prioritize resource allocation based on the potential for greatest clinical and financial return. Prioritizing care gaps for each member and quantifying potential cost savings associated with care gap closure guides care teams in knowing where and how to focus care team resources.

Prescriptive analytics allow for further prioritization of members based on their willingness and ability to comply with prescribed interventions. An intervenability category can be assigned to members based on such factors as barriers to compliance - social determinants of health, lifestyle factors, behaviors and geography. Care teams are able to then focus time and resources on members who are most likely to engage and improve health outcomes through known, preferred communication channels.

Extend the channels of engagement

One critical component of an effective engagement strategy is ensuring it offers the right channels of communication members want to use. Rather than relying only on the telephone, payers should enable their care teams with expanded digital engagement including app-based chat, email and direct texting. They can then use the method the members themselves have said they prefer and look to analytics to determine the optimal frequency of touchpoints with various populations and sub-populations to drive results.

Make a larger, broader impact, locally

A member-centric care delivery model that is informed by data and analytics and wrapped with an interdisciplinary team will support the ever-changing and complete needs of members. When and where possible, bringing that care locally, and meeting members where they are will deliver heightened engagement, improved health outcomes and better cost management.



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Average: 4.3 (3 votes)

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

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