Care Management

Care Management is the first publication in the ACHP series Health Plan Innovations in Patient-Centered Care.

The issue:
  • An estimated 75 percent of U.S. spending on health care goes to the treatment of patients with chronic diseases; an aging population means that this spending will only continue to grow.
  • A fragmented delivery system makes it difficult for many patients with chronic illnesses and complex needs to coordinate their care across multiple physicians, specialists, medications, or treatment options.

The solution:

  • Care management — the coordination of care for patients with complex health care needs — has emerged as a way of improving quality of care for patients while reducing health care costs.
  • The ACHP Care Management Brief and Handbook are comprehensive looks at how health plans can improve the patient experience through the use of care management nurses who work one-on-one with members.

While there is no “one size-fits-all,” we found some keys to success:

  • Innovation. An important part of a care management program is flexibility and a willingness to adapt to meet changing needs of populations.
  • Close partnerships. ACHP plans found that working closely with providers, patients, and community-based organizations – through frequent face-to-face encounters, provider/nurse “huddles” and extensive familiarity with community-based resources – help address all of a patient’s clinical and non-clinical needs.
  • Payment Incentives. Payment incentives can be significant factors in the success of care management programs by encouraging hospitals and providers to partner in their implementation. Fee-for-service generally is not conducive to care management programs.

A section on Outcomes demonstrates plans’ successes in improving health outcomes among patients, reducing health care costs, and maintaining high satisfaction rates among members. The bottom line:

  • Community-based health plans are partnering with physicians, provider practices, and community organizations to improve care for patients living with chronic disease.
  • Care management programs at the health plan level can focus on each patient holistically, including social and environmental influences of health, with a broad perspective on multiple conditions and complex needs.