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Integrated Care Management Delivers Value to Recipients, States

Historically, healthcare has focused on a person’s … health.

As we’ve learned more about the significant role that social determinants of health play in a person’s well-being, however, providers are realizing that they must focus on whole person care. This includes not only patients’ medical, dental and behavioral needs, but also their social needs. In fact, we are seeing care management, which has traditionally focused on medical needs, shifting to not only looking at social needs, but sometimes looking at them first.

Aggregating and Assessing Data

Just as a health risk assessment (HRA) can score a patient’s health, a health-related social needs (HRSN) assessment can identify unmet needs around housing, food and transportation that could affect a patient’s well-being. An HRA can frame up what a patient needs to do to improve medical outcomes, with the care manager suggesting steps to help the patient achieve their goals. The HRSN assessment pinpoints issues that must be stabilized before the patient can fully focus on these medical needs. If transportation is an issue, for instance, the patient could be connected to taxi vouchers or bus passes. If there is food insecurity in the home, the patient could be referred to a community food bank.

Both medical and social information can be collected in almost any situation: primary care visits, case manager interviews, mailings — whatever best engages the patient. In fact, the opportunity to collect valuable information exists any time a patient interacts in any type of healthcare setting. Data from a variety of sources can provide a rich, holistic picture of a patient’s health and well-being — that is, when the data is made available to the care team. Oftentimes, however, this data is locked up in silos across multiple organizations.

This is where care management platforms come in.

Automating and Standardizing Processes

An effective care management platform can pull data from multiple, diverse sources and seamlessly aggregate it into one convenient location, enabling informed decision-making. The platform is much more than just a data repository, however. When built on a solid foundation of automation, standardization and mature processes, it makes the data not only available, but also useful and actionable.

The right platform allows providers, specialists, care managers and even the patient to exchange data. This simplifies care coordination and allows the entire multidisciplinary care team to have the same view of the patient, as well as a unified plan for the patient’s journey. As each team member interacts with the patient, the information is updated, and the view of the patient comes into even sharper focus.

Having everything in one place simplifies tasks and creates efficiency. It also allows care managers to be more proactive. For instance, imagine a provider has submitted a prior authorization (PA) request for a particular service. A care manager can see the PA in the system and know that there is a newly diagnosed disease, even before a claim is filed. With that information, the care manager can put interventions in place, without a delay in care.

Empowering Care Managers 

An integrated platform fully supports the entire process of care assessment, planning, coordination and management. All of the data, plans and processes are in one convenient place, supplementing a care manager’s knowledge with proven pathways that lead to improved patient outcomes.

Gainwell’s care management system, for example, provides standardized HRAs from nationally recognized colleges and academies that assess medical conditions such as diabetes, COPD and congestive heart failure. Another big component of our platform looks at health-related social needs. A utilization management module promotes the best use of resources, while ensuring high-quality care.

The system looks at a patient’s medical, behavioral, dental and social risks and history, and uses predictive analytics to automate care plans. Once the plan is established, standardized rules create a workflow to lead the team members through a series of tasks, empowering them to make data-driven decisions. The flexibility of the platform allows clients to configure the system to their own best practices and specific model of care — without requiring a technical effort on the part of users.

Providing the Right Information at the Right Time

To make it easier for patients to receive help, it’s necessary to make it easier for care givers to give help. An interoperable care management system does just that, equipping care managers with the right information at the right time.

For those of us who live and breathe healthcare, we forget that not everyone understands the healthcare system like we do. People don’t always know where to get help — and sometimes, they might not even know that they need help. Truly integrated care management allows those of us who can more easily navigate the healthcare system help those who can’t.