The Forum

The #1 barrier to scaling your care management programme (and how to fix it)

by Rachel Zuckerman and Vidal Seegobin

We've shared previously some of the keys to improving care for high-risk patients: targeting the right patients, tailoring care to each patient's starting point, and addressing non-clinical needs. With these tactics, patients will likely demonstrate better control over their conditions and rely on the hospital less. But what happens next?

The right route to avoid 3 pitfalls of chronic disease management

Most organisations have set up care management programmes to run in perpetuity, with no 'end date' or decision point when a patient might be deemed ready to leave the programme. There are legitimate reasons for this: patients and their care management team often grow attached, patients are reluctant to lose their dedicated support team, and providers are hesitant to give up oversight. Further, it's difficult to assess progress and know when someone is truly 'ready' to manage their care more independently.

Endless enrolment a lose-lose for patients and providers

But ultimately, leaving patients permanently enrolled in intensive care management programmes is not ideal for patients nor providers. Patients want to live as independently as possible. They want to spend minimal time in health care settings so they can spend more time at home doing the things they love with their friends and family.

At the same time, health care organisations want to reach more patients with their limited resources. Because of the intensive nature of the work, care management programmes can only support a finite number of patients at one time. Holding onto patients indefinitely means that programmes are more likely to reach capacity quickly, which prevents more patients from participating. It also limits health care organisations' ability to scale otherwise effective programs.

To overcome this challenge, we've seen successful organisations make passive management the goal of their high-risk patient programmes. 'Passive management' is when the patient owns their own care and is in control of their conditions—they're self-managing. They have limited interactions with the care team, but maintain ties to the health system for support when needed.

The simplest way to make passive management a reality is by establishing a clear 'graduation' point to transition patients out of the programme.

How to implement a successful path to graduation

Lancaster General Health, a health system in Pennsylvania, US, has embedded graduation into Care Connections, its care management programme for high users of care. Enrolled patients receive routine home check-ins from a care navigator and have regular visits with a multidisciplinary care team.

Patients are enrolled in the programme for three to nine months and see impressive results. Lancaster has measured a 42% drop in emergency department visits and a 54% drop in patient admissions among participants.

Here's how Lancaster has successfully embedded graduation into their programme—and how you can, too:

1. Set graduation expectation at the start. Care Connections is branded as a temporary, high-intensity program, and the onboarding process highlights self-management as the end goal.

What this means for youClearly establishing that your programme is not permanent ensures all participants—both patient and provider—understand the expected length of the programme and are on board with its objective from the very start.

2. Establish clear criteria to assess readiness to graduate. Lancaster has clear metrics to determine when a patient is ready to transition out of the programme. For example, a patient must meet at least 50% of their care plan goals and show improved psychosocial risk scores. This means that patients graduate based on individual progress, rather than a predetermined, one-size-fits-all timeline.

What this means for youWhile your programme's graduation criteria may be different, the important thing is having a clear definition of the transition point that everyone can rally around and feel comfortable relying on.

3. Celebrate achieving the goal. Care Connections applauds newly minted self-managers with an informal graduation ceremony with family, members of the care team, and other patients.

What this means for youHelping high-risk patients reach a point of self-management is often a long and complex journey. Recognise it as a milestone of success to boost patient and staff morale and give others inspiration to continue on the same path.

4. Create a clear protocol to transition patients out. The Care Connections team conducts a warm handoff back to a patient's regular GP for ongoing care, with occasional care navigator check-ins as needed.

What this means for youThe right balance of follow-up support will vary by programme and even by patient, but it's crucial to have a plan in place to reassure staff and patients that 'graduation' doesn't mean patients are on their own.

The right route to avoid 3 pitfalls of chronic disease management

Learn how to avoid three common pitfalls that lead to poor patient outcomes and elevated costs. Use this infographic to share these key principles across your organisation.

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