1. Make psychosocial support accessible in high-risk care management models
Targeting high-risk patients is a necessary first step when determining the reach of your ambulatory care management program. These patients incur the highest cost and need the most care because they often have unaddressed non-clinical needs that complicate clinical treatment and drive up costs. Key focus areas for successful management include consistent communication, psychosocial and care transition support, and ongoing monitoring.
The University of Michigan uses RNs and social workers to co-manage the clinical and psychosocial needs of its population's most risky patients. RN care navigators are embedded in primary care practices and support chronic disease management for a subset of the high-risk patients. Meanwhile, the centralized social workers actively manage about 200 patients during acute psychosocial crisis (e.g., chronic pain exacerbation with multiple ED visits). Social workers coordinate symptom management with patients' PCPs, coach patients in self-management, and connect them with community services (e.g., medication and transportation assistance).
2. Deploy rising-risk care management to prevent escalation of chronic conditions
The next step in devising a system-wide care management strategy is to include rising- and low-risk patient populations under management. It is not sustainable, nor necessary, to enroll rising-risk patients into the same intensive care management programs needed by high-risk patients. The goal of rising-risk care management is to prevent escalation by focusing on proactive chronic disease management and care transition support.
Rising-risk care management caseloads range from 100 to 1,000. The range in panel size varies due to the degree of ongoing care needed by patients, especially care transition and self-management support. Some organizations provide in-person management, while others offer only telephonic care management services to their rising-risk patients. The best way to scale rising-risk care management is by facilitating patient self-management and leveraging community partners where and whenever possible.
3. Standardize low-risk care management to scale screening and proactive education
Finally, to achieve system-wide care management, teams should evaluate key services for low-risk patients. These patients don't require personalized care management, but they do benefit greatly from healthy lifestyle education and reminders to utilize preventative care. Centralized and standardized workflows are important ways to meet the needs of the sizable low-risk patient population.
Centralized staff responsibilities can include electronic outstanding orders and appointment reminders, online education programs, as well as service follow up or monitoring if appropriate.