By Pat Stricker, RN, M EdSVP of Clinical Services
TCS Healthcare Technologies
As the role of case management in patient care continues to strengthen, especially as health care reform initiatives take effect, more emphasis is being placed on how to best identify, track, and monitor patients who would benefit from care coordination.
The first step – identifying specific groups of individuals to receive case management – is a challenging part of the process, traditionally accomplished with such methods as utilization review or inpatient admission/stay information. Thanks to advancements in predictive modeling, however, the options for identifying the right individuals for case management services are expanding.
With opportunity comes challenge, of course. Thus, as the potential for more accurate and effective targeting of case management patients grows, the expectations of payors and other sponsors of case management are increasing in return.
For example, the Centers for Medicare & Medicaid Services (CMS) is promoting the Medicare Shared Savings Program (MSSP), as part of the Patient Protection and Affordable Care Act (PPACA). CMS is encouraging the creation and implementation of new Accountable Care Organizations (ACOs) to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs for certain medical treatments and services.
Risk Assessment & Resource Allocation
A key element that will determine the success of ACOs and similar programs utilizing case management services will be how they identify, track, and address risk. Risk can be classified in several ways, including risk that we can avoid altogether, and risk that we can manage. In terms of where we can manage risk, it is important that case managers identify, allocate, and benchmark the use of resources that impact financial and clinical outcomes for the targeted populations.
With the program goal of generating the "biggest bang for the buck," case managers need to determine which groups have the most potential for significant impact, based upon the allocated resources that are available. Case managers have been and continue to be able to identify and address opportunities similar to what CMS is trying to do with the MSSP.
Risk Measurement
After identifying, stratifying, and assessing risk factors accurately, case managers need to be able to deploy specific interventions to measurably reduce or eliminate the identified risks. Feedback loops need to be established to track the progress of the financial and clinical metrics being used to impact the targeted populations and provider groups/networks. Transparent and objective benchmarking is key.
Leveraging IT Solutions
With growing expectations to disclose the relationship between costs and clinical outcomes, case managers are being pressed to become more familiar with data analytic and population management tools. Knowing what type of system to use can be daunting. Leveraging the right IT solution can be a huge help in identifying, stratifying, and reporting risk.
Interestingly, the results of the 2012 Health Information Technology Survey, sponsored by CMSA, TCS Healthcare Technologies, and other health care organizations, indicates that more work needs to be done in this area. For example, only 12% of the respondents said they have a case management software system that "predicts future medical costs related to an individual or a selected population," and only 15% report that their IT system allows for "return on investment (ROI) calculations for financial performance." These percentages must increase, in order to be successful in managing risk.
A myriad of vendors offer applications designed specifically to help case managers address the "risk" challenge with the goal of optimizing case management outcomes. A Health IT Trend Report will be published shortly discussing some of these applications. In the short term, click here to view the Trend Reports that have been published to date.
With increased expectations by payors like CMS to manage risk and by leveraging the right IT solutions, risk management programs (including identification, assessment, interventions and benchmarking of risk) will continue to evolve rapidly. Case managers need to stay abreast of these developments and emerging opportunities as they occur.