The goal of care management is to engage patients in their care and equip them to self-manage their health long-term. This journey inevitably involves two inflection points: care management enrollment and graduation.
How to engage patients 101
Though they take place at opposite ends of the care management experience, effective enrollment and graduation rely on the same factors: having distinct eligibility criteria and clear operational processes.
Look beyond utilization to identify patients eligible for care management
Providers that lack sophisticated population health management strategies or risk stratification tools tend to take reactive approaches to identifying potential patient enrollees. For example, a health system might identify candidates based solely on high emergency department (ED) utilization resulting in hospital admissions.
Narrowing patient enrollment solely to reactive identification methods instead of proactively risk stratifying the broader population limits the potential to improve outcomes. Systems are likely to overlook countless patients for whom upstream interventions could prevent acute care utilization.
Develop standard protocols and expectations around outreach
Follow these steps to optimize your outreach processes and drive enrollment:
- Develop easy-to-follow, explicit eligibility criteria and share it widely among your staff. This makes the process easier for your clinicians, support staff and health care partners to refer the appropriate patients to the outreach team.
- Implement multiple avenues for outreach, including in-person warm handoffs and phone calls. Create guidelines to ensure staff use their time effectively, such as placing a limit on the number of unanswered phone calls to make to a prospective patient.
- Train enrollment staff on "sales" competencies—staff should be able to engage patients, provide program details, and clearly communicate program benefits.
- Leverage various touchpoints where eligible patients to seek treatment to conduct outreach. Within the clinic, care managers can receive warm handoffs from the care team; in the inpatient setting, care managers can visit eligible patients at the bedside. For patients who don't regularly interact with the health system, use phone-based outreach.
- Tailor messaging to your target populations. To engage patients, it's important to explain from the get-go why the service would be right for them. Provide outreach staff with scripting to help them engage different types of patients.
Introduce the concept of graduation from the get-go
According to Advisory Board's care management redesign surveys, one of the strongest drivers of unsustainable care manager workloads is patients staying enrolled in care management longer than necessary. It's understandable: Patients grow accustomed to care manager support, and care managers become emotionally invested in their patients. Setting up graduation as a goal and accomplishment sets expectations early: When patients and their care managers can work toward clear objectives, it helps them both view care management as a tool helping patients get to self-management.
Implement workflows to ensure graduation readiness
Some organizations have instituted step-down support to ensure patients are truly ready for self-management before they graduate.
Gundersen Health System in La Crosse, Wisconsin, divides patients into "active" and "monitoring" categories. Care managers check in with patients who have improved and learned how to self-manage their conditions every two months to monitor any decline and track their progress in the EHR. Ultimately, the most stable patients are discharged from the program.
By clearly outlining criteria and instituting workflows to guide patients toward self-management, Gundersen has maximized care manager capacity while simultaneously ensuring patients receive the support they need.
Editor's note: A version of this post was originally published as the fifth post in a blog series by Tomi Ogundimu in partnership with Ensocare. The original post can be found here.
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