Building a Care Management Program

Building a care management program—and leading it—can be made easier with these three steps.

By Medecision

Leading a care management program doesn’t come without its challenges. Not only are you responsible for managing and administering multiple functions across medical and clinical operations—but you’re also charged with guiding the design and strategy of various population health and care management programs, evaluating the effectiveness of those programs, coordinating with health plan leaders on clinical interventions, and ensuring compliance with a number of performance, contractual and regulatory requirements.

When it comes to planning and building a care management program, start with these three steps.

Step 1: Decide which populations to include.

Care management programs typically focus on one or more of the following areas:

• Improving the health of members with specific chronic conditions such as asthma, diabetes, congestive heart failure, coronary artery disease and chronic obstructive pulmonary disorder
• Segmenting an entire population into risk levels and allocating resources accordingly
• Providing high-touch care to high-risk members
• Taking a population-based approach with population-wide goals (e.g., lowering obesity rates or improving mental health), but with interventions appropriate to each member’s risk level or disease
• Targeting highest-use members in an effort to reduce the costs and occurrence of hospital readmissions and provide guidance toward appropriate care sites

Step 2: Identify and stratify eligible members.

Clinical data can be used to identify and stratify at-risk or high-risk members and intervene appropriately. Risk stratification helps identify patients who are most likely to benefit from care management—thus reducing unnecessary utilization and improving health outcomes.

In a 2016 report, the Association of American Medical Colleges suggested that the “use of predictive modeling to proactively identify patients who are at highest risk of poor health outcomes and will benefit most from intervention is one solution believed to improve risk management for providers transitioning to value-based payment.”

In a 2019 article published in Family Practice Management journal, Dr. James Dom Dera writes about his practice’s two-step approach to risk stratification. Step one involves “sorting patients into one of three risk groups (high, medium, and low) based on objective data” that is taken from claims data or the electronic health record. In step two, patients are assigned to one of six risk levels based on how physicians and staff answer the following questions:

• Is the patient healthy with no medical problems? If so, are his or her biometrics in or out of range?
• Does the patient have chronic conditions but he or she is doing well?
• Does this patient have chronic conditions that are out of control but without complications?
• Does the patient have complications of chronic disease of high-risk social determinants of health?
• Is the patient potentially in danger of dying or being institutionalized within the next year?

This two-step approach of combining objective data and subjective input, Dr. Dom Dera writes, allows his team to better assess an individual’s risk level and categorize them at the appropriate level—and it’s an assessment that can be used for both provider and payer care management programs.

Step 3: Enroll members.

Consider strategies that will be used to enroll members and retain them long-term, such as:

• Targeting condition-specific gaps: Segment your audience and create campaigns specific to the benefits of managing certain chronic conditions through your care management program. For example, if you offer a program that helps individuals with Type 2 diabetes monitor and manage their blood sugar (e.g., with free testing strips, monitors and lancets), market that program accordingly.
• Enrollment campaigns: Email campaigns to targeted populations highlighting the advantages of care management programs can improve enrollment rates.
• Educational components: Share educational materials such as branded literature and pamphlets that explore the benefits of enrolling in a care management program.
• Continued outreach: Keep members engaged with condition-specific educational support, healthy living tips, responsive customer service, easy access to personal healthcare information, and reminders about the benefits of adhering to care plans or taking advantage of available member services.

Next steps in building a care management program?

To read more about building a care management program that’s primed for the future of digital consumer engagement, determining which conditions to target, ensuring social determinants of health are addressed, and measuring care management program effectiveness, download Medecision’s whitepaper “Create and Implement Next-Gen Care Management Programs.”