Care Management: A Critical Component of Effective Population Health Management

医疗保健支付系统的前所未有的变化导致全国各地的卫生组织投资于追求医疗保健改善研究所(IHI)的三重目标，以改善人口健康，改善患者的体验和结果，并降低人均成本。¹卫生组织必须制定有效的人口健康管理战略，它们需要正确的数据和分析来为其行动提供信息。

Once armed with the information to make data-driven decisions, leading healthcare providers are implementing care management programs, which have proven to be helpful mechanisms for achieving the Triple Aim. Many healthcare organizations have identified specific patient cohorts to monitor the impact of care management interventions on individual and population health outcomes.

Data-driven care management programs that target high-risk and rising-risk patients can achieve impressive results, including:

• Up to 20 percent lower rates of hospitalization in mature care management programs.
• 急诊使用率较低。
• Decreased costs.

CARE MANAGEMENT PROGRAM ENABLES PROVIDERS TO DELIVER ON THE TRIPLE AIM

The shift to value-based care and changes to healthcare payment models are prompting healthcare leaders to renew their focus on the Triple Aim. Population health, which is best defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group, is at the heart of these conversations because it impacts all three of those important dimensions.²Organizations with effective population health initiatives rely on analytics to help their leaders make data-driven decisions—and those analytics are essential to every step, from identifying patient cohorts to measuring the effectiveness of initiatives.³

An organization’s success in managing population health is dependent upon the ability to make informed decisions about its entire strategy. The key strategic pieces include identifying populations or cohorts of interest, obtaining health outcomes data for the cohorts (such as mortality, disease burden and injury, and behavioral factors), examining experience of care, and determining per capita cost (total cost of care, and hospital and emergency department utilization rate and/or cost). An analysis of these combined data points provides organizations with much-needed insights to design and deliver the right set of services that improve care, improve population health, and reduce costs per capita. Organizations must measure and evaluate the effectiveness of their initiatives as related to all facets of the Triple Aim.

An increasingly common and critical component of effective population health strategies is care management. It is defined as “a set of activities designed to assist patients and their support systems in managing medical conditions and related psychosocial problems more effectively, with the aims of improving patients’ functional health status, enhancing the coordination of care, eliminating the duplication of services, and reducing the need for expensive medical services.”⁴

Leveraging data and analytics for care management

文献支持护理管理是改善三重目标的有益机制，但如果组织没有获得正确的数据和分析，他们在这一领域的成功有限。对于许多组织来说，确定哪些患者会从参与护理管理项目中获得最大的好处，并对他们的风险进行分层，甚至是第一步都是一个挑战。所以，他们通常简化他们的方法，只确定成本最高的病人是队列中的一员。然而，单一的成本数据点不足以告知服务的设计和交付。最佳的预测模型整合了来自多个来源的数据，使组织能够识别出哪些患者处于危险之中，但还没有严重到无法从项目中受益。这些先进的模型还研究了药物信息、诊断测试和健康的社会决定因素，更能预测风险上升和未来成本。与仅依赖历史索赔数据的旧模型相比，这些模型在风险分层方面也更好。

拥有一个复杂的预测模型是至关重要的，但它仍然没有价值，除非有人对这些信息采取适当的行动。在确定高风险和风险上升的患者后，专家需要对患者的健康需求和可用的社会支持进行全面评估。详细的评估，以计划服务，以支持病人改善他们的健康和降低成本，需要比初级保健医生在普通访问收集更多的信息。为了确定需求和协调服务，组织需要有关功能状态的信息，这可以确定患者如何进行日常生活活动。这个评估可能包括准备饭菜、体育活动、交通、经济资源、社会参与和社会支持方面的问题。组织还需要了解患者和护理人员的偏好，因为不符合患者偏好的护理计划是不可能有效的。

While, care management is imperative for healthcare organizations, it’s nearly impossible for primary care providers to perform this complex and comprehensive assessment as a part of their routine clinical work. That’s where care managers come in. After the completion of this thorough assessment, care managers must then develop a care plan that addresses the patient’s needs. The care plan should be tailored to the individual patient’s needs, and should be something in which the patient can successfully participate. The multi-faceted plan should address both immediate needs and longterm care goals, and it should clearly identify who is responsible for each service. When the care plan has been established, care managers can turn their attention to monitoring the patient’s health status and communicating with the patient. Although experienced care managers are best suited to perform this work, they are in short supply.

Making care management work at five top healthcare organizations

Addressing these challenges and getting started with a care management program can be difficult and overwhelming. Thankfully, success stories are available from peer organizations that have already tackled some of the challenges and achieved impressive results. Many healthcare organizations have leveraged information from their Health Catalyst Analytics Platform, including their Late-Binding™ Data Warehouse (EDW) and broad suite of analytics applications, to support the identification of specific patient cohorts to monitor the impact of care management interventions on individual and population health outcomes. The programs featured below focus on different patient populations, but they share major commonalities. The themes of aggregating data to identify and risk stratify potential patients, focusing on care coordination functions, developing processes to improve patient engagement, and importantly, measuring performance, are prevalent throughout the examples (see Figure 1).

Care management program successes

• Leaders at Partners Healthcare, an integrated delivery system and accountable care organization (ACO), developed the Integrated Care Management Program (iCMP) using data from the EDW to identify and risk-stratify patients who could benefit the most from the program. Once high-risk patients are enrolled in the iCMP, they are matched with a nurse care manager who works closely with them and their families. Team members at Partners provide ongoing training to new and existing care managers to ensure that an adequate number of skilled care managers are available. To balance the workload and provide appropriate assistance to each patient, care managers and their teams manage a mix of low-, medium-, and high-risk patients, with approximately 200 patients assigned to each care manager. The care managers assess patient risks and needs, including comprehensive functional assessments and potential barriers to care. They closely monitor patients during office appointments; looking for gaps in understanding or the ability to comply with the established medical treatment plans; use phone calls and home visits to monitor patients after visits; and coordinate services such as diagnostic tests, transportation, social services, and specialist services. Care managers also serve as liaisons between the patient and other members of the care team across all settings. Leaders at Partners use data from the EDW to calculate the return on investment (ROI) for the iCMP, and to compare the iCMP patient outcomes to non-iCMP patients.
• Allina Health has several examples of effective care management, including its heart failure (HF) management program and the Courage Kenny Rehabilitation Institute (CKRI).The HF management program at Allinais designed to overcome persistent challenges with care coordination, particularly a lack of a clear ownership of the HF care management process, which is a common issue at large healthcare organizations. The program focuses on five main functional areas: nursing, care management, protocols and guidelines, measurement and reporting, and education. Each area is led by a cardiologist, and the care management function is co-led by a cardiologist and a primary care physician. There is also a nurse dedicated to that function who follows HF patients in all settings of care. The nurses see HF patients at the hospital, understand their care plan, and assure that the plan is executed after their discharge.Similarly, the CKRI at Allina provides comprehensive rehabilitation services for people with short- and long-term conditions, injuries, and disabilities.At CKRI, an experienced registered nurse serves as the assigned care manager，帮助患者和他们的护理人员理解和导航复杂的医疗服务系统。护理管理人员从诊断到治疗期间都有，他们与一名护理指南和一名社会工作者一起工作，所有这些人都合作满足患者的支持需求。通过使用EDW和分析平台，CKRI团队成员可以轻松识别并世界杯厄瓜多尔vs塞内加尔波胆预测锁定高危患者，规划干预措施以满足独特的患者需求。来自EDW的数据也使他们能够证明ROI和改善的患者结果，由护理管理举措。
• MultiCare是一个专注于高危心脏病患者护理过渡的综合交付网络。Patient navigators serve as advocates and care managers, helping patients navigate the complexity inherent in any large health system. The navigators are the voice of patients. They are responsible for making sure that patients’ preferences are honored, that they receive the proper education, and that they understand all the information. The navigators make follow-up appointments for patients and ensure that they attend those appointments. They also work with patients on medication adherence. In addition, they serve as a communications liaison, informing care teams of changes in a patients’ conditions.
• Texas Children’s Hospital has taken a population health approach to diabetes care management with children, incorporating focused improvement efforts in the clinic, community, and inpatient arenas, including comprehensive patient and family education. For each child diagnosed with diabetes, Texas Children’s identifies their risk for diabetes ketoacidosis (DKA) and mobilizes additional support such as a dedicated high-risk social worker for those patients at greatest risk for DKA. Data and analytics from the EDW inform their improvement efforts and enable data coordination across the continuum of care.
• Leaders at El Camino Hospital, a multi-specialty community hospital, identified that their care managers were overextended and that attempting to manage too many patients had decreased their ability to be effective. As part of a broader effort toreduce length of stay (LOS), El Camino’s leaders increased the number of care managers available in the emergency department and expanded the support provided to the acute units. These staffing changes improved discharge planning by ensuring that patients had the knowledge and supplies (medications and durable medical equipment) to safely transition to the next care setting. The team focused their efforts on patients at high risk for readmission by following up with them post discharge to confirm that they could successfully manage their care. These efforts helped the health system to avoid costly and unnecessary admissions.

RESULTS

Data-driven care management programs that target high-risk and rising-risk patients can improve the patient experience and outcomes, improve population health, and reduce costs per capita. The five health systems highlighted here have implemented innovative programs with exciting results, which have profound implications for providers across the country.

At Partners, patients enrolled in the iCMP are reaping the benefits, including improved patient satisfaction and:

• 降低了20%的住院率
• 13 percent lower rates of emergency department (ED) utilization.
• 25 percent relative difference in mortality.
• 12%的总储蓄。每花费1美元，该项目至少节省2.65美元。

Allina’s HF management program decreased readmission rates by three percentage points, and its CKRI program is improving outcomes and cost, including:

• 7 percent reduction in hospitalizations.
• 住院天数减少7%
• 46 percent reduction in ED visits.
• 在出院180天内降低8%的继发性中风率。

In addition:

• 多主体医疗系统对护理过渡的关注成功地降低了再入院率和住院时间，同时也提高了死亡率。
• Texas Children’s has sustained a LOS reduction of 44 percent, achieved an 86 percent influenza vaccination rate among patients with diabetes, and has reduced recurrent DKA admissions by 30.9 percent.
• 埃尔卡米诺成功地将平均LOS降低了7.8%，同时在再入院方面也实现了14.8%的相对改善。

WHAT’S NEXT

保健管理将继续是人口保健战略的一个关键组成部分，各组织将需要采取数据驱动战略，以提高效率。未来，医疗领导者将完善和提高风险预测模型的准确性，并将努力实施与患者风险水平直接相关的循证干预措施。

REFERENCES

1. Institute for Healthcare Improvement. (2016).Triple aim for Populations Overview.Institute for Healthcare Improvement.
2. Lewis, N. (2014).Populations, population health, and the evolution of population management: Making sense of the terminology in US health care today.Institute for Healthcare Improvement.
3. Stiefel, M. & Nolan, K. (2012).A guide to measuring the triple aim: Population health, experience of care, and per capita cost.Institute for Healthcare Improvement.
4. Bodenheimer, T. & Berry-Millett, R. (2009). Follow the money – Controlling expenditures by improving care for patients needing costly services.New England Journal of Medicine, 361(16), 1521-1523.

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