Six Best Practices to Address High-Risk, High-Cost Members Through Care Management

May 4, 2020 HMS

In recent years, population health has become a higher priority in the healthcare sector. The Centers for Disease Control and Prevention (CDC) describes population health as “an interdisciplinary, customizable approach” that enables change to happen at local levels. It uncovers significant health concerns and highlights ways that resources can be used to address the causes of population-level problems.

According to the Advisory Board Company, if healthcare organizations want to shift to a population health-based approach, it requires proactive engagement of patients in lower-acuity settings. Care management is a logical strategy for health plans to use to identify high-risk members and to intervene before health problems become dire, leading to costly emergency room visits. In fact, the Agency for Healthcare Research and Quality (AHRQ) believes that care management is a leading strategy for managing the health of populations.

To ensure that care management programs support population health, health plans may want to consider six best practices:

  1. Clearly define what population health management means for your organization. The Advisory Board Company recommends creating a focused strategy for population health, based on your organization’s definition. Care management goals aren’t “one size fits all.” They will be unique to the needs and characteristics of each plan’s population and market. Goals should be linked to performance metrics.
  2. Identify populations with health risks that are modifiable. According to the AHRQ, a modifiable risk factor is one that a person can control. If modifiable risk factors are minimized, it is more likely that an individual will live longer and have a higher quality of life. It’s not uncommon for a single member to have multiple modifiable health risks.
  3. Expand your view to social determinants of health. Many health plans and healthcare providers focus exclusively on traditional medical needs. In the world of population health, it’s essential to also look at social determinants of health. Examples include ethnicity, whether or not a member smokes, availability of caregiver support and more.
  4. Align staff with the specific needs of member populations. It’s critical to focus care management resources on members who will benefit most from these services. It just makes sense to invest in care management for populations that have high-risk conditions that are costly to treat. Directing care management services to these groups is particularly important for value-based payment models.
  5. Deliver care management to members during transitions of care. Members often need additional attention when they move between different care settings, such as from the hospital to rehab, or from the emergency room to home care. Data gathered by the AHRQ suggests that poorly managed transitions are correlated with higher risks of adverse medication events, higher hospital readmission rates and higher healthcare costs.
  6. Leverage care management technology to extend the reach of limited human resources. Care management solutions like HMS Essette enable plans to stratify member populations by risk level and create cohorts. Once care plans are developed, managers can easily involve interdisciplinary care team members, identify specific interventions and conduct individual assessments. It’s impossible to provide intensive care management services to all members, but technology-based solutions can help plans reach more people.

The goal of population health is to improve health outcomes in the communities that health plans and providers serve. Care management is an effective way to make population health a reality. Members who receive care management services are more likely to get higher quality care, since they are directed to the appropriate preventive care. Safety is also enhanced, since services like medication reconciliation across providers avoids duplication and errors. The healthcare system as a whole enjoys higher efficiency as unnecessary utilization of high-cost services like visits to the emergency room decrease and individuals get the care they need in lower acuity settings.


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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