It’s impossible to achieve reasonable and prudent member care management in a vacuum. The three-legged stool supporting care management includes medical management, risk assessment, and medication therapy management. The care manager cannot make reasonable decisions about a member’s care unless he or she has knowledge of the member’s medical management history and current status, medication history and current status, and diagnostic history and current status based on risk assessment.
For example, a member with heart failure needs to be looked at holistically to ensure he or she is not at risk for a medical event with the increased expense and poor outcomes. Is he or she compliant with his or her medication regimen? Has there been a change in his or her blood pressure or weight? Has the volunteer delivering the member’s meals noticed a change in cognition or responsiveness?
The horizon of members ranges from those very healthy requiring little additional monitoring and outreach to those requiring almost daily monitoring and frequent communications. How can health plan care managers organize and create care plans for members with exactly the right combination? The answer is timely data collection and analysis of that data. Care managers need just-in-time information and dashboards that ensure members needing immediate attention are easily determined. This may include predictive modeling or systems programming to alert care managers to “triggering events” such as a hospital admission or transition between care settings, changes in pharmacy utilization, or change in diagnosis. For example, with the heart failure member mentioned above, the member-recorded weights reveal a five-pound weight gain in the past three days, and the volunteer form from the meal delivery service indicates the member seemed more confused—two signs this member needs to be contacted, and an increased level of medical management may be needed immediately. The data and reports are nothing without a routine analysis of your care management structure (e.g., program descriptions, policies and procedures), staffing, training, and supporting technology.
Care management without current data becomes a game of “whack a mole”—whichever member is costing the most amount of money is the one who gets addressed first. A proactive program with multiple points of information available allows care managers to plan and respond timely to member information and, therefore, avoid “care management by crisis.”
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