Care management is an important clinical strategy to improve patient health and quality of life by reducing the time a patient spends in the emergency department (ED) or hospital battling chronic conditions. It is also a key lever for accountable care organizations to lower total medical expense for their high risk populations.
Care management programs can also help reduce the often-significant burden placed on individual providers who are part of risk-based contracts. Primary care providers often do not have the necessary resources to provider social support services, patient disease education or help navigate multiple providers. A highly functioning care management team can assume a great deal of that complex care for this cohort of challenging patients, directly resulting in an improved care coordination and increase provider satisfaction.
However, a care management program can only improve patient care if the organization can implement it in a financially sustainable way. The goal of bringing together clinicians, financial team members, and data analysts is to build a program that can sustainably provide high-quality care and improve the quality of life for patients and lower total medical expense resulting in returns on investment for the program.
A Northeast hospital system participating in an accountable care organization (ACO) began analyzing ED visits over time by practice and provider, along with utilization drivers like primary diagnosis and utilization trends for patients with specific conditions. The hospital found that patients with chronic obstructive pulmonary disorder (COPD) were frequently going to the ED to be treated for pneumonia.
The hospital established a quality measure across all care settings to understand whether patients with COPD were getting their pneumococcal vaccinations, used its quality team to identify high-risk patients, and conducted an outreach campaign to get COPD patients vaccinated.
A year after launching the vaccination campaign, the hospital saw a 41.5% reduction in ED visits for patients with COPD.
A multi-state ACO serving 250,000 patients wanted to reduce avoidable ED utilization across its network.
The ACO rolled out a patient education campaign, and then used predictive analytics to identify current and predicted high ED utilizers and enroll them in care management workflows. Care managers assessed the root causes of ED use for each patient and collaborated with the patient and the primary care provider to develop a care plan with appropriate interventions.
The ACO reduced avoidable ED visits more than 23%, from 365 ED visits/k to 296 ED visits/k and continues to see a downward trend as it rolls out more care management initiatives.
A large Northeast ACO was able to provide care management services to significantly more patients, tripling the number of patients served by its nurse care managers from 2016 to 2018.
By implementing care management technology, insights from aggregated EHR and claims data, standardized workflows, and workforce engagement, the ACO enabled an increase in nurse care manager caseload from an average of 65 to 70 in 2016 to an average of 91 in 2018.
These results were seen by mature organizations with well-established care management programs. In general, organizations embarking on care management journeys should expect a roughly 0-5% improvement in any given metric.
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