When it comes to developing a complex care management strategy, cardiovascular program
leaders can’t afford to wait. But since comprehensive care management is still a new competency for many programs, they often don't know how to get started.
This study offers a step-by-step solution. You'll not only learn what a successful care management plan looks like, but how to develop and implement one of your own.
Today's CV leaders are more accountable for long-term quality and costs, and they’re facing an increasingly chronic and comorbid patient population. In 2011, an overwhelming 97% of the highest-cost Medicare patients had at least one cardiovascular condition.
This means the traditional focus on reducing 30-day heart failure readmission rates is no longer a sustainable care management strategy. CV leaders will have to broaden their approach to succeed under value-based care.
Read more about the case for comprehensive care management
So what does a comprehensive care management strategy look like?
For one, it's comprehensive in scope, not in scale. Providing complex care management for all patients is practically and financially impossible. Instead, CV programs should focus on the highest-risk patients who are most likely to drive up costs and benefit from more individualized care.
But targeting the right patients is only one part of a successful care management effort. The best plans are:
And with the help of the best practices we've mapped out below, you'll be able to develop and implement a plan that meets these criteria.
13 steps to care management success
Develop a cohesive CV care management strategy
- Set clear goals that align with institutional objectives
Related tool: Mission statement template
- Make a compelling case for institution-wide support
Related tool: Ready-to-use presentation
- Audit existing efforts for duplication, gaps, and efficacy
Related tool: How-to guide for auditing care management initiatives
Related tool: Care management program benchmarks
- Define metrics to track your progress
Related tool: Metrics picklist
- Assemble a dedicated CV care management team
Related tool: Staffing audit
Related tool: Job descriptions
Related tool: Staffing benchmarks
Identify your highest-risk patients
- Risk stratify patients at the point of admission
Related tool: Risk stratification tool compendium
- Identify psychosocial barriers
Related tool: Psychosocial risk factor assessment
Related tool: Family caregiver assessment
- Tier resources based on patient risk
Enhance their inpatient care
- Implement high-risk rounds
Related tool: Metrics to evaluate round efficiency
- Create a forum for multidisciplinary collaboration
Related tool: Complex case conference charter
- Formalize partnerships for comorbid care
Support their outpatient care
- Coordinate and streamline post-discharge care plans
- Bridge the gap between discharge and PCP follow-up
Related tool: Ambulatory care transition team referral form
- Partner with high-risk outpatient clinics
Related tool: High-risk transition clinic referral form and brochure
Benchmark your program
Get the conversation started
Chronic Care Management
Patient Focused Care