Does Your Care Management Team Focus Solely on “Superutilizers”?

January 30, 2020 Jason Cooper

It may be time to take a different approach…

When healthcare professionals think about care management services, they typically direct their focus to high-risk, high-cost members. New Jersey’s Camden Coalition of Healthcare Providers, for example, has been widely publicized for its Hotspotting program. Historically, this initiative has focused on individuals referred to as “superutilizers” – that is, people with serious health conditions who are frequent visitors to hospitals, doctor’s offices and emergency rooms. After superutilizers were discharged from the hospital, the Camden Coalition deployed a team of nurses, social workers and community health workers to help coordinate their outpatient care and connect them with social services.

Recent research by the New England Journal of Medicine (NEJM), however, suggests that this approach isn’t producing the desired outcomes. In the NEJM study, 800 hospitalized patients were randomly assigned to either the Camden Coalition’s care-transition program or to usual care. The 180-day hospital readmission rate between the two groups was not significantly different — 62.3% of individuals in the intervention group were readmitted, while 61.7% of people in the control group were readmitted.

Where should care managers direct their energy?

Although current care management practices focused on the most critical patients haven’t generated desired outcomes, this doesn’t mean that care management should be discontinued. Rather than just focusing on critical, high-risk members, health plans must try to prevent these members from getting to the critical state in the first place by shifting the focus to “well care,” not just “sick care.”

If an individual’s health profile shifts from low-risk to rising risk, opportunities may exist for early intervention. Identifying these opportunities is only possible, however, if the healthcare system is monitoring health status on a consistent basis.  Equally important is identifying hidden risk which isn’t necessarily apparent to care teams — where an individual has a “ticking time bomb” and underlying, unmet health needs.

When care management teams leverage predictive and prescriptive analytics, they can proactively engage patients and coordinate the right care intervention at the right time to address hidden and rising risks. By arresting risk progression, healthcare systems can get ahead of issues before they become critical. This approach will become increasingly important in the world of value-based care. For value-based care organizations, a significant key to success is getting the treatment plan right in the first place for the right individuals. Failures in approach and focus are often paid for at the healthcare organization’s expense.

Prescriptive analytics can highlight what organizations can do now for patients to avoid costly issues in the future. Since payers hold much of the administrative and cost data that can be used for prescriptive analytics, they can help providers work more effectively under a value-based care model. Proactively supplying data to providers on a regular basis can drive medical loss ratio (MLR), quality and experience improvements.

Conclusion

Though our healthcare system has profound and systemic shortcomings, we clearly need to better understand and address behavioral and social health across populations. Healthcare organizations of all sizes may be able to prevent patients from getting to the critical category in the first place by using predictive models, prescriptive next best actions and personalized member engagement interventions for preventive care.

 


To learn more about how health plans are broadening their care management scope beyond “sick care” to include “well care” initiatives, download our white paper.

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