Challenges and Opportunities in Health Care Management

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HUBweek Healthcare Delivery Innovations –Mass General Hospital High Risk Care Management

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The Current State of Care Management: A Frustrating Workflow

Schijns , Janjaap Semeijn. Kotze , Kelvinne Mocke. References Publications referenced by this paper. How to zero in on supply chain savings. Materials Management in Health Care, 22— Pursuing supply chain gains. Gene Long. Information technology mediated Business Process Management - lessons from the supply chain Frederick Hewitt.

READ MORE: How to Get Started with a Population Health Management Program Diabetes, congestive heart failure, smoking cessation, obesity, avoidable readmissions, and unnecessary emergency department use are all excellent initiatives to pursue, but most organizations do not have the capacity to attack every single problem all at once. Instead, providers must ask themselves which initiative will save the most money and produce the most measurable clinical improvements with the least amount of effort.

Starting small with a clearly-defined pilot case, such as increasing vaccination rates for flu and pneumonia, can serve as proof of concept for executives while helping an organization develop a foundation of best practices for future use cases. This is one instance where it is very clear than an ounce of prevention is worth many, many pounds of cure. After 14 months of the vaccination program, pneumonia immunization rates for adults older than 65 increased from 4 percent to 34 percent, saving on primary care and hospital spending for a vulnerable, high-cost demographic.

In order to manage a population, providers have to know how many patients fall under their responsibility. As a result, providers may be financially responsible for patients that have not yet come into the clinic for an evaluation. For providers participating in value-based care contracting, failing to develop an accurate portrait of all attributed patients can be a serious problem.

Many attribution methodologies are retrospective, noted Lucas Higuera, MA, and Caroline Carlin, PhD from the Medica Research Institute in a recent journal article , and finding the balance between scope and stability can be a significant challenge for payers and providers. READ MORE: Using Risk Scores, Stratification for Population Health Management Ideally, attribution rules should try to include the maximum number of patients possible, thereby balancing the ratio of high-needs patients to healthy patients, but not include so many patients that the turnover rate is impossible to manage.

Providers should work closely with their payers to understand the methodologies employed in patient attribution and how shifting populations will affect incentive payments and quality metrics.


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Risk stratification is an integral part of population health management. Once an attributed population has been established, providers must identify their highest risk individuals and target appropriate interventions as necessary. Engaging in comprehensive risk stratification requires a familiarity with data science and access to health IT tools that can proactively identify trends and pinpoint opportunities for improvement.

Assigning risk scores to patients based on the number and complexity of their chronic diseases, socioeconomic challenges, spending patterns, and physiological risk factors can help providers forestall crisis events and engage patients in wellness activities before conditions worsen. Many healthcare organizations are purchasing health IT products, such as EHR modules or integrated population health management platforms, which can deliver the analytics and reporting required to access the necessary insights.

Many organizations used to the fee-for-service environment rely on a relatively straight-forward staffing structure centered on delivering support to physicians, who conduct the majority of patient-provider interactions. A population health model, however, can be somewhat more decentralized, with nurses, PAs, care managers, social workers, behavioral health experts, and specialists all deeply involved in coordinating services and achieving goals for an individual patient.

For some providers, developing a coordinated care team and the technology to support it may require hiring new staff members or shifting current resources to new positions. While the initial outlay for a new nurse or care coordinator may seem daunting to an organization operating on a tight budget, these professionals may quickly produce a return on the investment due to more efficient, proactive care delivery.

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Financial bonuses from succeeding with incentive programs and pay-for-performance initiatives may also cover the start-up expenses of a population health management initiative. While providers can certainly engage in team-based, patient-centered care programs without shouldering financial risk, participating in a shared savings model, accountable care organization, or bundled payment program can provide an enticing revenue opportunity.

Providers just starting out with population health should consider one of a number of upside-risk only models, which reward participants for meeting or exceeding benchmarks without making them financially liable for falling short. More advanced organizations can explore downside or two-sided risk models , which promise bigger bonuses for success, but also include penalties for failure. The shift to collaborative, team-based healthcare supported by robust health IT infrastructure will require providers to adjust their workflows and communication strategies.

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Providers may wish to convene focus groups and stakeholder panels to ensure that all members of the team can provide input into process changes and new workflows, Ellis suggested. Giving everyone a seat at the table can foster a sense of ownership and involvement that is likely to smooth the adoption of innovative patient care strategies.

Effective chronic disease management requires individuals to understand their condition and how to control it, maintain consistent contact with healthcare providers, and have access to community and family support that will help them maintain their health.

While providers may feel somewhat frustrated that they are now more responsible for what patients do outside the four walls of the clinic, patient non-compliance can usually be mitigated with just a little extra effort on the clinical side. Barriers may include a lack of transportation or childcare, the inability to take time off of work to attend appointments, confusion over how to take medications appropriately, or concerns about how to pay for expensive services.

Challenges and Opportunities

Providers should take the time to discuss these issues with patients during in-person visits so they can design personalized management programs that best address their needs. Complex patients often require care from several different providers across the healthcare spectrum.


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  • While vendors, providers, and other stakeholders are starting to make headway with health data interoperability, moving patient information back and forth between disparate systems is still one of the foundational challenges of taking a population health approach to care. Vendors and providers seem committed to working through challenges identified in the study.

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