Author: Deb Hagemann, Associate Vice President, Clinical Management Services
This blog is part of An Inside Link, a series of posts authored by the subject matter experts at Clearlink that offer insider knowledge and tips across a range of industry specialties.
According to the Centers for Disease Control and Prevention, six in ten American adults live with at least one chronic disease, and four in ten live with two or more, leaving health plan members with high-risk conditions to compete for resources to support their care needs. Although individual member populations are small, they require many nuanced services to yield positive outcomes. Navigating the prevention and management of multiple chronic conditions is one of the most challenging issues the healthcare community faces today.
After nearly two decades of leading teams in managed care and driving clinical product development, I’ve found that health plan case managers can make a difference in the lives of complex, high-need, high-cost members through several transformative interventions.
Taking action on these initiatives starts with identifying the high-risk individuals in your member communities.
Identifying High-Risk Members
Who are your high-risk members? They’re most often identified as having multiple comorbidities and psychosocial conditions, a history of repeated and preventable hospitalizations, poor health-related quality of life, and a general lack of psychosocial aid to address their health needs. They may be diagnosed with arthritis, cancer, COPD, coronary heart disease, asthma, diabetes, hepatitis, hypertension, stroke, or weak or failing kidneys.1
Many people with multiple chronic conditions have common negative experiences when it comes to pursuing healthcare services:2
- They face barriers navigating the healthcare system and accessing care
- They end up seeing multiple providers in multiple care settings
- They obtain avoidable late-stage diseases from care access difficulties
- They utilize more services and must contend with higher healthcare costs
High-risk populations are clinically and socially complex, requiring case managers to adapt to the needs of individual members and employ the right interventions at the right time. If identified too late, members at risk of health complications won’t obtain the proper care plans to improve their health status—and the health plan itself will endure unnecessary costs for mismanaged care.
Case managers can address these concerns and encourage better care for members by implementing care coordination interventions, which, when targeted and well-designed, have been found to boost participant satisfaction, lower inpatient admissions, help prevent unnecessary care, improve overall health outcomes, and reduce total medical expenditures.3
Care coordination can take many forms, and there are five key ways case managers can increase their abilities to effectively identify and manage complex, high-risk populations.
1. Develop a Training Curriculum
Case managers need to know how to actively engage with high-risk members to encourage them to take recommended actions that improve their personal health outcomes. These actions can be small, such as taking short daily walks, adding healthy foods into their diet, reaching out to a friend for support, or regularly visiting their primary care provider.
Because these members require complex care, case managers must build competencies that allow them to fully understand and address member needs. Invest in training that helps case managers form beneficial relationships with assigned members by offering education in areas like:2
- Behavior change approaches
- Motivational interview techniques
- Clinical and diagnostic reasoning
- Biopsychosocial interconnectedness
- High-level, empathetic communication
2. Leverage Healthcare Analytics
Payers have access to large volumes of claims, utilization, pharmacy, medical, and ER data to segment their member populations. This data can be a powerful tool in illuminating population health management trends and opportunities that may translate to new member enrollment, better member outcomes, and stronger member retention, among other health plan improvements.
Make an effort to capture and analyze your healthcare data, creating dashboards, data modeling tools, and risk stratification algorithms to further define at-risk populations and identify affected members for care management engagement.
3. Optimize the Member Experience
Achieving higher member satisfaction can help health plans strengthen enrollee retention, enhance health outcomes, and increase STAR ratings. Once members are identified for care management engagement, conduct a brief assessment related to each member’s condition to inform the case manager as they create a short-term plan in partnership with the member.
With the right approach, case managers can gain members’ trust by reassessing their needs and satisfaction levels frequently, engaging the assistance of family and friends, and celebrating wins, small or large.
4. Know Your State & Local Resources
Determining appropriate community resources that may benefit your members can be difficult. Such community resources are vital for identifying the Social Determinants of Health (SDOH) impacting member health and wellness, from homelessness and poverty to health illiteracy. Assessing conditions like economic stability, education, social and community-based healthcare needs, and safe housing can close SDOH-related care gaps.
Be sure to address SDOH in your care management assessment to gain a comprehensive understanding of your members’ needs and priorities. Without a solution to connect each member to their required services, they may face a higher risk of complications within their medical or behavioral health conditions. Online databases like findhelp.org can provide local resources for supporting SDOH needs.
5. Learn Behavior Change Techniques
Once you have assessed the care management of your members, you’ll likely have some recommendations to share. How do case managers communicate these recommendations to your members? Many clinicians, like myself, know that it’s not easy to simply inform members of the changes they need to make in order to improve their health. Members may not be ready for change, fully understand why change is necessary, or have the resources to make change happen.
Situations like this prove that behavior change technique training is essential for modern case managers. A framework like the Stages of Change Model can help case managers consider how open members are to adjustments and how to best guide them toward positive behavior modification and ultimately better health outcomes.
Improving Care Models, One Population at a Time
The shift to coordinated, value-based care begins when payers define their at-risk populations and invest in trained case managers who proactively lead members to the right care. With a targeted, holistic population health management approach, organizations can lower the total cost of care and improve the health and well-being of their members in the process.
If you don’t know where to start, turn to the experts at Clearlink. Our care management program design services typically begin with a detailed assessment that includes testing your team’s current knowledge and advising on the ideal behavior change training curriculum for your case managers. Schedule a consultation with our team today!
- Prevalence of Multiple Chronic Conditions Among US Adults, 2018, CDC Research Brief
- Transforming Care for People with Multiple Chronic Conditions: Agency for Healthcare Research and Quality’s Research Agenda, Health Services Research
- High-Risk Care Coordination: Opportunities, Barriers, and Innovative Initiatives in Medicaid, Institute for Medicaid Innovation