People around the world are experiencing an unprecedented rise in chronic conditions due to aging and unhealthy behavior. Recognizing the potential for crisis, health care is entering a new era of fundamental change. A fee-for-service model made more sense in a world where communicable diseases were more prevalent. Now, preventable, chronic diseases are the world’s biggest killer. The health care industry must turn its focus toward value and outcomes, while also containing costs, which is impossible to achieve without finding new ways to efficiently manage and coordinate care.
Transition to a connected care model
Experienced medical professionals do a great job of managing care within their own walls, but what happens after a person steps outside their office? When people are sick and in need of extensive health and care services, the responsibility falls on them to coordinate and manage their own care. Often, this leaves a person bouncing around the health community, shuffling records from doctor to doctor and trying to juggle appointment schedules.
By empowering people through technology and processes, we can transition to a more connected model of care. Responsibilities need to be clear, information needs to be shared and it is imperative that care team members start working together as a unified team with the patient at the center. While there isn’t one single solution that does it all, a holistic care management strategy can aid in the surveillance, coordination and facilitation of care across all venues, providing a more seamless experience and cohesive care effort.
Considerations for implementing a holistic care management strategy
To support healthier outcomes, a holistic strategy supports a wide variety of health needs, including transitions, chronic condition management, medication therapy management, complex case coordination, behavioral health and short-term risk management (e.g., high-risk pregnancy). Before implementing such a strategy, the following components need to be taken into consideration:
Aggregate and normalize disparate data to form a single source of truth for each person
The more you know about a person, the better-informed are your decisions. It is not about generating more data, but taking advantage of data that already exists. Each interaction creates, or has the potential to create, new data about a person. These data points are oftentimes left scattered across the community, only telling a partial story of a person; therefore, this disparate data must be aggregated, normalized and reconciled to form a single longitudinal record for each person – a comprehensive summary of a person’s health and care.
Identify target populations
Once organizations have a better sense of the members of a population, they can rely on predictive intelligence to target people who would benefit from proactively planning and coordinating their health and care activities.
To do this, identification algorithms sift through the data to flag those that meet specific criteria are assigned to an appropriate community care manager - who can begin engaging individuals in discrete groups.
Proactivity is crucial as health care moves away from the fee-for-service model. You can’t wait for an acute event to occur to engage those that can benefit from care management. Waiting for an acute event is akin to buying fire sprinklers after the house is on fire; most of the expense has already happened.
Create a care plan for the care continuum
Healthier outcomes don’t just happen overnight. Care management is a complex process of surveillance, coordination and facilitation of care across all venues, varying according to a person’s health status, goals and personal drivers. Having a plan is essential and community care managers are at the front lines when it comes to implementing this plan.
As community care managers proactively reach out to dozens of individuals each day, they reference each person’s customized care plan built from intelligence derived from the longitudinal plan. The plan suggests how conditions should be managed across the continuum, recognizes gaps in care and proposes steps to resolve them.
Working from this plan, they will add additional information, schedule appointments and promote education that can be shared with the person and all members of the care team.
Provide smooth transitions between settings
Acute episodes should not cause a pause in the care management process. When an acute event occurs, the health system’s acute case manager and acute care team works from the same longitudinal record and plan as the community care manager. By connecting acute case managers and community care managers, smooth transitions between venues support better experiences and outcomes.
Prepare for the future
Health is both personal and complicated. A holistic, personalized care management strategy that is scalable across populations supports people beyond a single episode, empowering them to take charge of their health.