Identifying the need, developing a tailored plan, and engaging with the patient and other providers are among the best practices cited by experts and researchers for effective care management. White papers published by Health Care Transformation Task Force and the Center for Health Care Strategies, Inc. (CHCS) point to the need for care coordination, particularly for high risk patients with chronic or complex conditions.
CHCS cites that fact that “Across the country, innovative states are implementing programs that provide ‘high touch’ care management for targeted groups of beneficiaries.” The organization’s research identified a number of best practices for care management, including:
- Stratification and triage by risk/need
- Integration of services
- Designated “care home” and personalized care plan
- Consumer engagement strategies
- Provider engagement strategies
- Information exchange among all stakeholders
- Performance measurement and accountability
- Financial incentives aligned with quality care.
The Health Care Transformation Task Force, in its paper titled Developing Care Management Programs to Serve High-Need, High-Cost Populations, states that “Effective care management programs will utilize both qualitative (physician- or patient-reported information) and quantitative (claims, electronic data) resources to identify high-need, high-cost patients.” The paper adds that care management best practices “will take a holistic, person-focused and family-centered approach to health including its behavioral, social, and physical aspects.”
Coordinating care for a patient includes consideration of the patient’s social determinants of health, involvement on the part of the patient as well as the patient’s family in the decision-making process, and physician engagement and communication with the patient as well as the patient’s other healthcare providers. As the Task Force explains it, “Best practice models of care management will emphasize care coordination across providers and have robust primary care capabilities at their center.”
Utilizing an effective electronic health record (EHR) to collaborate enables the providers to communicate with the patient and with each other, and, more importantly to automatically share updates directly from the Clinical EHR. Other providers get immediately notified so they can take action based on the most up-to-date clinical information.
The Task Force emphasizes that “Care management programs should be structured in a way that best suits the patient demographics and available resources of the provider organization, and care managers should work to engage patients and caregivers in creating the care plan and managing a patient’s health.”