Push beyond ordinary to extraordinary: Integrating care management into everyday practice

Today, as more people live longer, healthier and more active lifestyles, healthcare organizations can set up a more supportive infrastructure for the whole care team — inclusive of the patient — to improve the patient's overall health and well-being.

This content is sponsored by Cerner.

With the further adoption of risk-based contracting from state, federal and commercial payers, organizations are increasingly incentivized to manage a patient's overall health. The industry is in the early stages of transforming the way the system operates. As organizations look to integrate care management strategies into everyday practice to provide better services for the populations they serve, they will need to include providers, employers, payers (private and commercial), family/proxies and community organizations as part of the care planning process to facilitate success in today's challenging healthcare landscape.

"The term care management is often used interchangeably with care coordination, but the terms differ greatly in scope and meaning," Bharat Sutariya, MD, vice president and CMO of population health at Cerner, said in an interview with Becker's Hospital Review. The Agency for Healthcare Research and Quality defines care coordination as "deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care."

The term care management describes a broader, more patient-centric approach to managing chronic conditions that encompasses care coordination activities, according to AHRQ. The process encourages a holistic view of a patient in and outside of a hospital's four walls.

"Care management comprises activities like educating patients about their risks and conditions, understanding and eliminating their barriers to achieving health goals, enabling them to self-care and assisting them to coordinate care across the continuum," Dr. Sutariya said.

This article identifies the key components of a multidisciplinary care management program and discusses the clinical, operational and financial benefits such a program offers organizations.

Key considerations for implementing a care management program

An effective care management program must not only address a patient's immediate healthcare needs, but also their needs outside of the hospital, according to Lisa McDermott, vice president of population health strategy at Cerner.

"Clinicians often create a treatment plan based on care needs, such as required medications, diagnostic procedures or follow-up visits," Ms. McDermott said during an interview with Becker's. "But other factors can also affect a patient's ability to adhere to that plan. It's really the socioeconomic or environmental aspects that determine whether people can engage [in their care plan]."

Patients are frustrated with disconnected, fragmented care due to inaccessible health data and redundant processes, which often forces them to repeat their healthcare information to different clinicians across care settings. Organizations must create a care delivery infrastructure capable of identifying and addressing these pain points, while also empowering patients to take more responsibility for their health and well-being.

In addition to improving health behaviors, a care management program can help organizations achieve business goals, improve outcomes and control costs. Here are six crucial components to establishing an effective care management program:

1. Cross-continuum lens. Inpatient case management programs focus exclusively on an inpatient episode and appropriate care transition. Care management programs, on the other hand, broaden to address a patient's entire health journey. Therefore, organizations must design care management programs to cut across numerous care settings, according to Ms. McDermott.

"It's essential for organizations to think about [care management] as a broad, holistic service, versus taking an organization-centric approach," she said. "A cross-continuum lens is crucial for care management."

Ms. McDermott noted organizations need full organizational support to implement an enterprise-wide care management strategy. It's essential to implement a technology solution that supports a cross-continuum care focus and enables the level of communication and collaboration needed to support a successful care management strategy.

2. Longitudinal records. Before clinicians can effectively educate, support and care for a patient through a care management program, they must first understand the individual, according to Dr. Sutariya.

"You need a longitudinal record to stratify and comprehensively assess the individual to drive a longitudinal, personalized plan of care," he said.

Longitudinal records, which house a comprehensive summary of a patient's health history, help clinicians identify patients who could benefit from care management services and identify social determinants that may influence patients' ability to manage their health. The record, aggregated from disparate sources across the continuum, can also include other valuable information, such as an individual's native language, living arrangements and preferred communication method, according to Linda Stutz, vice president of care management services at Cerner.

"So much of the complexity in healthcare is because everything is so fragmented," Ms. Stutz told Becker's. "All of that information in one place helps provide end-to-end care management."

3. Multidisciplinary team approach. A successful care management program requires a multidisciplinary team approach in which all stakeholders work together to monitor and support patients throughout their health journey.

"Organizations must create longitudinal relationships with patients where everyone is part of coaching and surveillance," Ms. McDermott said. "Whether it's a primary care physician or an emergency department physician, it's important they see a patient's longitudinal plan and how it may change based on those interactions."

At any point in time, a care management team should be prepared to provide care coordination through various skill sets, according to Ms. Stutz. A team may include unlicensed healthcare professionals to aid in nonclinical aspects of care coordination — such as transportation and appointment scheduling — along with social workers, dietitians, pharmacists and financial counselors.

4. Automation. Automation is another essential component for a care management program, according to Ms. McDermott.

"A lot of care management programs are telephonic, where care managers pick up the phone and call the patient, but those are still scheduled interactions," she said. "We need to get to the point where we are gathering remote monitoring data, whether from devices or common health scales, and utilizing that data to decide when to reach out to the patient."

Automated transactions also include something as simple as texting appointment reminders to patients, according to Ms. Stutz. Interactions like this maintain a patient's engagement and accountability in their health while providing the rest of the care team with helpful information to discern how best to support a patient.

"Checking in on patients … through automated transactions provides the behavioral nudges we're used to in our daily interactions with technology," Ms. McDermott said. "Let them respond and help the rest of the care team know how to effectively engage the care manager."

5. Continuous model of surveillance. Care management programs should function as a continuous management model, in which the team members proactively monitor a patient's health and make changes as needed, versus an event-based model triggered by a hospital visit, according to Ms. McDermott.

For example, care team members might rely on "lifestyle coaching and virtual monitoring to proactively assess whether a patient's medication is effective," she said, instead of evaluating the medication regimen when the patient is next hospitalized.

Continual surveillance is also important to identify new patients who may benefit from care management, according to Dr. Sutariya.

"You need a proactive surveillance and monitoring system so when certain risks arise, you can identify the individual and enroll them into a care management program to mitigate the risk," he said.

6. Ability to self-evaluate. Organizations must not only continuously monitor patients, but also regularly analyze the care management program's own efficacy. This self-assessment requires a rich data and analytics system to help organizations learn and evolve, according to Dr. Sutariya.

"I think there needs to be recognition that we're still in the early maturity of the concept of care management," he said. "A technology-driven process improvement approach is key to a program's success. It's important to evaluate the operation, the result of the program and be able to evolve at a fairly rapid place."

The benefits of a care management program

Care management programs hold several benefits for patients, clinicians and organizations. For one, the care model helps patients gain a more textured understanding of their health.

"At a personal level, it gives patients the ability to understand their risks and conditions, which further motivates them to adhere to their treatment protocols," Dr. Sutariya said.

This knowledge empowers patients to take better care of themselves and achieve an improved health status or, at the very least, limit progression of their condition.

Care management also builds a stronger patient-clinician relationship in which the clinician serves as a "trusted partner in the navigation of the longitudinal plan," according to Ms. McDermott. Clinicians support a patient's activation and engagement in their health plan by addressing social determinants that may impede healthy behaviors and better outcomes.

For clinicians, care management serves as a mechanism to improve health statuses at an individual and population level, which is an invaluable tool for organizations operating under risk-based contracts.

On a larger scope, an effective care management program can help organizations reduce unnecessary utilization, because these programs aim to better control conditions and reduce hospitalizations. Cross-continuum care coordination can also enable organizations to achieve better patient flow, shorten length of stays and improve patient outcomes, all of which translate to lower costs, according to Ms. Stutz.

"If you can do a warm handoff and refer a hospitalized patient to resources immediately available in the community, the transition from hospital to home [will be much smoother]," she said. "You close care gaps, enhance the consumer experience and reduce complication risks and readmission."


As organizations shift to more risk-based contracts and the profit incentive flips, providers are more motivated to holistically treat the patient and the population. A multidisciplinary care management program can help with this transition. An integrated, multidisciplinary approach to care management, supported by enterprise-wide technology capabilities, can help improve patient health and create more beneficial clinician-patient relationships. Ultimately, organizations that allocate necessary resources to a comprehensive care management program are likely to see the most success in lowering costs, improving outcomes and boosting clinician and patient satisfaction, all of which are musts for success under value-based care.

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