Insight
Facing the Six Barriers to Cohort-Centric Care Management

>>Facing the Six Barriers to Cohort-Centric Care Management

Cohort-centric care management improves a person’s health by bringing the best of population management, care coordination, and patient/member engagement together.

The 2004 report, “Will Care Management Improve the Value of U.S. Health Care?” defined Care Management as programs that “apply systems, science, incentives, and information to improve medical practice and help patients manage medical conditions more effectively. The goal of care management is to improve patient health status and reduce the need for expensive medical services.”

At SDLC Partners, our healthcare services team helps payer and provider clients optimize and equip their care management program to achieve six objectives:

  1. Enable team-based care and collaboration
  2. Engage patient/member along with caregivers/family, and their community
  3. Address non-medical barriers related to social determinants of health
  4. Coordinate across care settings and help manage care transitions
  5. Choose and implement appropriate technology to administer care management activities, communication, tracking, and reporting
  6. Deploy the right care interventions at the right time

In this work, we have seen six areas where clients tend to struggle when working towards their value-based vision.

Challenge No. 1:

Having essential insight data top-of-mind during live interactions.

Many nurses and care managers/coordinators struggle to make the most of their live interactions with patients/members, especially if the contact is patient-driven. These opportunities of communication could be optimized if care managers had salient, contextual, and timely data points handy.

We’ve seen how technology, with strategically-placed alerts and data, can help the care management team seamlessly provide reminders or ask key health questions in the moment. These go further to build rapport and goodwill rather than checking a box or seeming cold and calculating.

We’re always asking, alongside our clients, “How close can we get to personalized care (that Segment of One) while maintaining a modicum of organizational and system efficiency?”

Challenge No. 2:

Bridging the gap between population management and addressing the needs of the “Segment of One.”

In today’s value-based care models, there is a greater emphasis on standardizing care for the population/cohort while addressing the unique needs of individuals through personalized care.

We’re always asking, alongside our clients, “How close can we get to personalized care (that Segment of One) while maintaining a modicum of organizational and system efficiency?”

Anytime we review protocols, standards or how technology is delivering those standards; we question how well each component addresses the population need or personalizes care for the individual.

Traditional transactional models don’t work anymore. Today, we’re building care management models that focus more on high-touch, high-trust relationships that work on the “next best action” that the member/patient or care team can take towards a common goal.

Challenge No. 3:

Expanding beyond “Big 4” cohorts into areas like behavioral health and addiction.

Most programs previously focused solely on the four, leading readmission chronic conditions: diabetes, hypertension, heart failure, and COPD. These conditions affect a large patient population and are the significant risk factors as it relates to outcomes and costs.

Today, more programs are looking at how they can use their existing program structure and technology to manage the unique care management needs of patients with mental health and addiction diagnoses, for example.

Payers and providers are updating their care management applications to address new and emerging value-based priorities. These could include new protocols, assessments, and connections to the community that enables collaborative support models.

Challenge No. 4:

Optimizing and Planning Care Management Resources and Patient Lists

Resource management has become a challenge as programs gain traction and payers/providers want to scale their initiatives without hiring a lot more staff.

How can your team manage the ebb and flow of population size and type, as well as changes in diagnoses that an individual nurse or care manager might need to coordinate?

We have built specific feature-sets that work with existing care management systems to allow for resource allocation and estimation and address this challenge.

Having a tool or capability to support team allocation becomes even more pressing as teams become decentralized and take on cohorts with greater complexity.

We prefer the term “inter-operation” versus interoperability.

Challenge No. 5:

Interoperability across teams, services, and the care continuum

Several categories of data are needed for effective cohort care management. At a minimum, any care management program should have access to patient-reported outcomes; social determinants of health; and activity-based costing to effectively manage a modern initiative.

We prefer the term “inter-operation” versus interoperability. By directly connecting systems and creating the bridges (e.g., a layer of code or process) among systems, programs can realize the vision of connectivity required to achieve value-based care, better clinical outcomes, and creating the best experiences for patients and members.

Interoperability sounds complex and unwieldy because it can be. Interoperation focuses on ensuring that only the critical data needed for your initiative and care management goals can flow easily among only those team members who need it.

Some research suggests that 80% of health outcomes are related to SDH. And, that 68% of consumers have at least some level of SDH challenge

Challenge No. 6:

Addressing social determinants of health (SDH) and community support

Some research suggests that 80% of health outcomes are related to SDH. And, that 68% of consumers have at least some level of SDH challenge, and 52% have a moderate to high SDH risk in at least one category.

Identifying and addressing these barriers is a priority for payers and provider organizations. However, acting on these needs, and connecting patients/members with the right community services, has proven more challenging than initially thought.

As you evolve your care management program, prioritize what SDH information you need to gather about your cohort.  Targeted assessments can uncover SDH barriers like health literacy, food scarcity, transportation challenges, and co-morbidities that may affect self-motivation.

If your care management program faces any of these six challenges, know that these have been solved before. Solutions for your unique program and cohort may include operational re-engineering, better care management technology or feature-sets, automation of behind-the-scenes tasks and communication, or improved data analytics and dashboards.

About SDLC Partners

SDLC Partners, L.P. is a Pittsburgh-based consultancy. With over 400 employees, we deliver high-performance digital solutions that create business and technology transformation.  As a high-growth firm, we have garnered awards and attention from the Pittsburgh Technology Council, the Inc. 5000, the Pittsburgh 100, and E&Y’s Entrepreneur of the Year.

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