Only a very small percentage of patients are enrolled in CMS's Chronic Care Management (CCM) program. Care management is a notoriously complex process, and getting paid for doing care management within the Medicare CCM program has been especially difficult.
Some physicians don't believe in the value of these preventive services, many don't know who is eligible for these services, and others deliver them but don't know the right way to code for them and miss out on getting reimbursed appropriately.
Advisory Board is working with two health systems that have built stellar care management programs. Both organizations took a unique approach to engaging their clinical staff but did not initially account for the critical role that technology—specifically the EHR—has in scaling the care management program and making their people much more effective.
People-driven care management must be top of the line, but it is only half of the equation.
One client, a health system in the Northeast, has built a separate complex care management program with a robust team of qualified care managers. The team is structured to recognize that each care manager has different strengths, so leadership identifies areas in which each care manager excels and maps their skills to patient needs. The organization's more than 120 protocols detail each step of the care management process for dozens of patient issues—medical, behavioral, and social—and are identified and delivered by the most effective and efficient team member.
Through this style of proactive care management, the system was able to reduce admissions, readmissions, length of stay and medical costs among their high-risk patient groups—and earned a share of the savings from Medicare for doing so.
Another large health system tapped its brightest clinical minds to create evidence-based content to support its care management strategy. In 2009, clinicians began building out care pathways for specific conditions, procedures and patient populations to provide better, more consistent care for the patients they serve. And health system physician leadership formed a governance structure to require providers and clinicians to identify evidence-based best practices and reach a consensus where evidence is lacking before rolling them out across the organization.
In general, there's an efficiency factor that's best solved by the EHR.
In both of these examples, processes and care pathways are largely human-managed, relying on a host of people across the broader care team to make the right decision for a patient individually—and creating a major efficiency problem.
Luckily for most organizations, the EHR can be positioned to help guide and prompt physicians' decision-making. The EHR, when applied correctly, can create a higher-level orchestration within care management that is usually missing with programs driven by staff alone.
The absence of efficiency from only people-led processes also creates a bandwidth issue. Many provider organizations, such as the provider in the Northeast, have the resources and capacity to build out care pathways and care delivery processes for one or two chronic conditions, but without the EHR, they are unable to scale best-practice processes across many different conditions.
The second health system, after developing care paths and realizing the need for higher physician adherence, embedded 10 to 12 care pathways into the EHR as of 2017. By doing so, care teams have been able to increase the power to influence behavior, improve efficiency through greater integration and improve care processes and outcomes. Furthermore, this client has been able to show significant care variation reduction. Care delivery teams have seen the stroke cost per day decrease by 25 percent and the observed mortality rate for ischemic strokes decrease by 43 percent since 2014 after the stroke care pathway was hardwired into the EHR.
The health system's medical director of informatics says it best, as he comments on the results his teams have had from building these care pathways into the EHR, "Proven…results include decreased utilization of testing, decreased hospital length of stay and post-acute utilization, and increased capacity and efficiency."
One ongoing challenge that remains particularly vexing is that each condition or population that needs management requires a different set of clinical and social interventions–and an associated, varied set of technical tools to support them. The example I like to use is how a coach might prepare for a basketball game. The coach has a fixed roster of players, but a good coach adjusts the lineup and runs plays to be most effective against specific opponents. Similarly, configuring EHRs to support adherence to different pathways requires a diverse set of EHR interventions. Curating, hardwiring and maintaining that diversity remains very difficult for most organizations.
Organizations need both people and technology to take some of the "busy work" off physicians' plates and drive care management best practices. And it's not just health systems that are affirming this truth. EHR vendors, such as Epic and Cerner, are making significant investments in helping organizations manage health, improve care and engage providers and patients in care delivery in a more automated way.
There's still much that needs to be learned in the care management space, especially if CCM billing requirements are to be met, but also to significantly improve care outcomes and efficiency.
This article first appeared on Health Data Management's "IT Think" blog.
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