Building A Care Management Program

Care management planning

Hot off the heels of this cinematic debut on how NOT to conduct care management comes this handy Alliance of Community Health Plans 29 page handbook review on how to do it right.  Some of the experienced members of the Alliance shared insights on successful population health approaches, data on the "return on investment" and how to deal with the physicians.

But, say the Hardball-inspired Disease Management Care Blog readers, "tell us something we don't already know." 

The DMCB found three useful nuggets of information:

1. There is no firm rule on the operational balance between central administration and peripheral distribution.  Some of the Plans hire and oversee the care management nurses while others pay their network primary care sites to hire their own nurses.  If the practices employ the nurses, they are free to let the managers see patients on an all-payer basis.

2. Care management caseloads vary from 35 to 150 persons and the enrollee to nurse ratio ranges from one full time nurse to 5000 to 14,000 commercial members. If less than 5000 Plan members are assigned to a primary care site, care managers split their time among multiple sites.  As Plan members are further diluted or distributed through a network, there is greater reliance on remote telephonic communication and coaching. 

3. Reduced costs?  Group Health, Fallon and Security Health plan say they saved over $2.5 million, $2.3 million, and $1 million, respectively. Tufts Health Plan says they saved $1.90 for every dollar spent.

Other points known but worth repeating:

Features of successful care management include appropriate patient selection, person-to-person outreach, credentialed professionals, teaming, coaching on self-management, family involvement and access to community-based programs.

Embedding care managers in the primary care sites is worthwhile not only because face-to-face patient care has more of an impact, but because the physicians will benefit from the consultations, participation in "huddles" and discussion of the treatment plans. That also leads to a greater level of trust between the docs and the nurses.

There's better buy-in if the care managers are viewed by enrollees as an extension of the physicians, not the sponsoring insurers. 

Technology is important: effective care managers are made more effective by electronic records, telemonitoring, decision support, work-flow aids and video/mobile communication.

 The backbone of care management is made up of generalist nurses who are simultaneously comfortable with multiple conditions such as, for example COPD, mental illness and diabetes.  That being said, there is a role for focused nurse support for patients with special needs, such as hospice, transplant or bariatric surgery.

An abundance of data support is only the beginning because the reports will need to be tailored to the physicians' clinical needs  and communication preferences.  They also have to be paired with regular meetings that promote best practices and solicit feedback.

When care management is first rolled out, physicians will first suspect this is another managed care ruse, assume it's a fast track to prior authorization or try to "downjob" clinical duties to the nurses that are outside of their scope of practice.  It will take many months and much collaboration to sort out turf issues, control, office space, and offering care management to some but not all patients.