Tag Archives: Care Management

Embedding Evidence-Based Medicine into Transitions of Care


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

Population health is a journey over time and provider organizations understand they must begin with the most impactful programs. Providers have to prioritize and focus initial efforts to quickly bend the needle on patient outcomes such as reducing readmissions. When organizations ask me where others are seeing tangible initial success, I often tell the following story.

An outpatient care manager at one of Caradigm’s existing customers shared with me that the value of population health technology became clear for her after getting a real-time alert one day that one of her patients was in the ED. She called the ED and was told that the patient’s blood glucose levels were extremely high, and the ED nurse thought the patient should be admitted. However, the care manager informed the nurse that the patient’s numbers were actually the patient’s baseline, and recommended that the patient did not have to be admitted, which saved an unnecessary admission. The outpatient care manager was able to devise and implement an effective plan of care to address a variety of contributing barriers to care, and the patient outcome was improved.

This story is about taking the right action, in the right time frame, in the right care setting. In other words, how do you embed best practices into workflows to reduce variation in care? How do you help patients move through a confusing and disjointed healthcare system that can be overwhelming to navigate? Transitions of care is an area central to population health that for many organizations is an excellent place to focus your population health efforts. The following are a few best practices to think about as you develop your strategy.

Facilitate access to primary care

Coordinated care is a proven value for high-risk patients, however, it is often a challenge for patients to access primary care soon after being discharged. Some organizations have found it effective to enroll high-risk patients into a Patient Centered Medical Home (PCMH) as a standard practice to get them better connected to primary care, a care coordinator and other community resources. Another approach is to partner closely with primary care clinics and even embed a care manager, a transition focused mid-level practitioner or social worker into the clinic to specifically serve high risk transitions patients. Even offering telephonic transitions of care support to coordinate scheduling for patient can help.

Standardize interdisciplinary care

When multiple levels of clinicians partner effectively with defined pathways and shared information, it’s amazing to see the impact. For example, psychiatrists and social workers going to a PCP’s office to speak to patients. Pharmacists calling physicians to say a prescription ordered is far more expensive than other options. Home health that directs patients back to lower acuity centers if needed, and works with patients to prevent unnecessary ED stays. Some provider organizations have had success identifying non-employed physicians interested in adding home visits as an additional revenue opportunity. Population health is truly a team sport and technology can help support transparency and care traffic control, making patients more confident in a team based delivery model.

Embed practices into workflows

After establishing your care protocols and pathways, care management tools can help ensure they’re followed consistently. Intelligent plans of care can have pathways embedded in the patient care plan, assuring that steps aren’t missed. Role-based tasking can help a team of clinicians take the right steps, in the right sequence, all while working at top-of-license. As mentioned in the story earlier, alerts can let the appropriate care team member know when a patient has a change in status, whether an ED visit, observation stay or inpatient admission. Lastly, as it is common for patients to be managed in multiple EMRs, technology can play a big role in streamlining medication review and in overall information sharing by aggregating data from multiple EMRs. Performing standardized readmissions assessments can help determine root cause, support an automated plan of care to mitigate barriers and perhaps even identify patterns or discharge practices of care that require change.

Improving transitions of care, supports long term success in advancing quality, patient experience of care as well as managing the cost of care. Organizations should be thinking about strategies for scaling, risk stratification, solving for social determinants and reducing variations in care. Wherever your organization is today, if you focus on meeting patients where they’re at and guiding them through what is a complex healthcare system, you will have succeeded in a foundational strategy for long term success.

How Bundled Payments is Driving Care Transformation and Patient Engagement


Post by David Lee


Product Marketing Manager, Caradigm

Bundled payments was one of the most discussed topics at the recent Caradigm Customer Summit, our annual gathering of industry leaders to share best practices in population health and information security. Matt Stevens, Senior Director with The Advisory Board highlighted bundled payments in his presentation as a program that CMS believes will push the needle in reducing cost variability while improving outcomes for high volumes of patients. He said more mandatory bundles (e.g. cardiac, expansion of Comprehensive Care for Joint Replacement) could be coming and that the intersection between bundled payments and MACRA is only likely to grow as it could become tied to the Advanced Alternative Payment Model (APM) track in the future. Matt recommended that hospital systems prepare to deliver both a broad clinically integrated network as well as excellence in individual bundles that can be decoupled and offered to patients in ways that offers them greater value.

We also heard a number of provider organizations (St. Luke’s University Health Network, United Surgical Partners International, Genesis HealthCare and Greenville Health System) explain why bundled payments is one of the most important pieces of their overall value-based strategy. The bundled payment program drives operational learning and experimentation so that expertise and care process improvements can be built, which then trickles down to other parts of the organization and to multiple populations of patients (e.g. Medicare, commercial populations). As that expertise grows, workflows improve and patient quality metrics improve (e.g. reduced readmissions, lower utilization), Our customers said this helped them gain confidence to scale their programs and also engage in additional value-based initiatives.

Another key aspect of bundled payments discussed was that it pushes providers to develop a high-touch patient engagement model. We heard from everyone that developing patient relationships is not easy, and that they take time. Not only is it a major change for patients to communicate more frequently with providers, the conversations are also different. For example, providers are now discussing with patients why it could be beneficial in certain situations to recover in their own homes rather than stay in a skilled nursing facility. We also heard one customer say that patients often hang up on them during a follow-up call thinking it’s a solicitation call. In this shifting dynamic, providers are trying to establish the groundwork for deeper patient relationships earlier in the care process so they can set the right expectations ahead of time.

Overall, it was exciting to hear that the bundled payments program is having a meaningful impact on patient outcomes and is helping organizations achieve financial success in value-based initiatives. We heard throughout the Caradigm Customer Summit that population health is where healthcare has to go to improve the health of the highest-risk patients. Bundled payments is a key program that will help healthcare providers advance down the path to population health. If you’d like to learn more about how Caradigm is supporting bundled payment initiatives through its enterprise care coordination software, then please send us a note here.

Filling The Care Management Tool Box


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.

 

 

[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.

 

Time to Value in Population Health


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

The stakes are high when it comes to population health as improved patient outcomes and long-term financial success are on the table. By now, most providers recognize the need to evolve. They must participate in new value-based programs, collaborate with other providers, and tailor workflows to support the changes. Implementing these changes is not easy! It takes significant amounts of time and resources from across the organization. When it comes to acquiring health IT tools to support population health, it often takes providers 9-12 months to evaluate the myriad of available solutions. I don’t blame providers for wanting immediate results after spending so much time investigating population health tools.

One of the key reasons why Caradigm formed its Care Transformation Team is to help customers achieve fast time to value following the acquisition of solutions. Our team serves as a sounding board for our customers who are making the shift to value-based care. We find that some organizations have been engaging in population health initiatives for years and are more mature in their processes while others can benefit from additional support. We tailor our approach to each customer’s strategic vision because it’s not one size fits all. The uniqueness of each organization has to be respected as we seek to identify common best practices and turn them into consistent processes.

I believe that all organizations should seek quick wins soon after acquiring population health technology. They are critical to building positive momentum for workflow transformation. The following are a few suggestions to consider when trying to achieve fast time to value in population health.

Plan early to achieve early success – establishing metrics and what quick wins look like prior to technology implementation provides a huge leg up in achieving them. Our team often collaborates with providers before contract signing to help clarify goals and expectations, and then align technology to them.

Define top value propositions – in addition to meeting specific metrics, population health tools can also deliver other types of value to end user clinicians. For example, the reduction of inefficiency or frustrating pain points for clinicians brings tremendous value to organizations and can be realized immediately. It’s important to document what the pain points and value propositions are in order to recognize that value.

Consider starting with care management – care management tools offer one of the quickest paths to value in population health because they can help remove numerous workflow inefficiencies that are impeding providers today. These can be items like having to hunt for data from multiple sources, having to manually generate care plans, or even being unaware when a patient is admitted to the ED. Care management solutions also give providers flexibility in where to start as they can begin by improving how they manage patients in a particular program, by disease category, or by focusing on a particular area of care management such as improving transitions of care.

While the road to population health can be long, organizations can achieve significant victories along the way. In fact, achieving those smaller wins should be celebrated as care transformation takes many small steps in the right direction. If you’d like to discuss how Caradigm can help you achieve quick time to value in population health, then please reach out to us here.

Engaging High Risk Patients through Care Management (Part 2)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

In part one of this post on engaging high-risk patients through care management, I discussed how different patient segments require different levels of care management relationships and tools. For the highest risk patients, a patient engagement strategy is centered on high intensity care management. Next, let’s look at how technology can help care management have a greater impact on outcomes for the highest risk segment.

Coordinating Care Across a Multi-Disciplinary Team

The care for a high risk patient can involve a large team including multiple specialists, pharmacists, care managers, office assistants, community health organizations and family members or friends. Coordinating activities among a diverse team requires shared access to a longitudinal patient record that gives a comprehensive “360 degree view” of the patient. The 360 degree view includes information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Dynamic care plans
  • Lab results
  • Medications
  • Patient outreach information
  • Patient supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Barriers to care
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

With this enriched view of the patient, care team members across the continuum can work more efficiently together closing gaps in knowledge and communication while operating at the top of their license. This can result in reduced redundancy in assessments, surveys and tests. Today, enterprise population health technology can bring together and make available all of this information in a shared workspace even if the information is stored in disparate IT systems.

Incorporating a patient-centered approach

A deeper understanding of patients helps drive a patient-centered approach, which is critical for patient engagement. For example, if a patient is motivated to achieve a certain goal such as travel to her daughter’s wedding, then every member of the care team can reinforce her motivation and encourage the patient and engage them in the plan of care. If every care team member has access to all patient information, then patients won’t have to repeat the same information to different care team members and patients begin to sense coordination among providers. If there is a family member, friend or community organization that plays a key role in the patient receiving care, then that critical piece of info will be incorporated into the assigning of tasks. The end result is a personalized plan of care. If patients see that the entire team “knows” them, it improves the overall patient experience, builds trust and can improve engagement.

Optimizing time with patients

Care managers are often challenged by a high volume of daily manual tasks. For example, in order to assess a patient and complete a care plan, care managers must track down and synthesize information from multiple systems and offline sources. With a full case load, efficiency is a challenge that ultimately impacts the amount of time care managers can spend focused on patients. Technology can help care managers spend more time with patients by automating time-consuming tasks. For example:

  • Care plans, task lists and interventions can be automatically generated and updated from assessment responses
  • Complete medication histories can display order history and fill history to enable faster review and support compliance review
  • Patient workloads or specific tasks can be reassigned to other care managers or support staff, assuring “top of license” activity
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).

To summarize the main takeaway from both posts, patient engagement and care management strategies are closely linked and should be tailored by segment. As part of population health initiatives where the focus is often on high-risk patients, patient engagement strategies should be on a one-to-one basis, and linked to relationship building through high-intensity care management. New population health technology has emerged to help coordinate care for the highest risk patients. As more providers make the shift to value-based care and seek efficiencies to help them scale programs, I believe that technology will play a central role in helping the highest risk patients. If you’d like to discuss your care management strategies in more detail then send us a note here.

Engaging High Risk Patients through Care Management (Part 1)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

One of the most challenging issues in healthcare today involves “patient engagement”. It is defined by the Center for Advancing Health as “Actions individuals must take to obtain the greatest benefit from the health care services available to them”. The importance of patient engagement is undeniable. Patients active in the participation of their own care have a greater likelihood of achieving successful outcomes. How providers should approach patient engagement for different patient segments is still an evolving science. Patient engagement requires different levels of care management relationships and tools for different segments. In this two-part blog post, I am going to focus on the highest risk segment, and will address lower risk segments at another time.

Population health management is a large undertaking, requiring a variety of approaches to assure broad impact. The figure below shows an example of patient segmentation along with the types of care management relationships and tools appropriate for each segment. At the top of the pyramid is the highest 5 percent in terms of risk. In the middle are the 30 percent of patients with rising risk. The base of the pyramid is the 65 percent identified as having low risk. Let’s examine the segments more closely to see how patient engagement and care management strategies can vary between the segments.

CM Pyramid

 

High Risk

The top 5 percent of patients require high-intensity, 1 to 1 care management involving a multi-disciplinary team. Patients may have comorbidities that require more complex coordination across the continuum of care. Due to the high clinical risk for this group of patients, a care manager needs to play a lead role within the care team, guiding patients to take the actions needed to obtain the greatest benefit from the health care services available to them. Therefore, a patient engagement strategy for high-risk patients is really centered on high-intensity care management providing direction to the appropriate level of care and education about symptom monitoring and action plans.

Rising Risk

In general, the rising risk segment requires moderate intensity care management services, referred to as condition management in the diagram. These patients can pose an escalation risk if unmanaged, so the emphasis is on providing a consistent set of evidence-based care or education about self-management of a newly diagnosed condition. Patient engagement for medium risk patients is often a combination of consistent patient outreach and communication along with tools to encourage self-management. Within this group, there can be a subset of patients identified as “movers”, patients whose level of clinical risk is predicted to increase over the next 12 months. Higher intensity care management can be appropriate for “movers” in order to proactively address their conditions before they become more acute.

Low Risk

The low risk segment is the largest group, nearly two-thirds of the population. The focus for this segment is on preventive health and wellness to provide age and gender appropriate recommendations for care. Wellness tools including patient education and coaching may center around lifestyle choices and illness prevention based on health risk assessment data. Due to the size of this segment, low-risk patients must take on more of the responsibility for self-care. They are the ideal segment to benefit from patient engagement and outreach tools such as an interactive portal and patient reminders.

In the second part of this post that will be published next week, I will go deeper into technology designed to achieve effective high-intensity care management.

How Population Health Enriches the Patient Record


Post by Sameer Bade, MD


Vice President of Clinical Solutions, Caradigm

As providers seek new capabilities to help them in their journey to population health, one of the first items they usually target is analytics. Analytics are undoubtedly an important piece of a population health strategy, however, this is just one of a number of important capabilities providers must obtain. In my experience collaborating with providers, a sometimes overlooked capability is creating and sharing a comprehensive, enriched longitudinal patient record. With the shift from physician-focused, episodic-care to team-based care involving multiple clinicians and care givers, it has become essential to have a real-time, 360 degree view of the patient that is shared among the entire team. With that enriched view, a care team can more effectively and efficiently deliver coordinated and proactive patient-centered care that drives improved outcomes. Let’s explore this issue in greater detail.

The reality is that clinical information from a single electronic health record (EHR) provides only a small portion of the information needed for population health management. If there are multiple EHR’s in a clinically integrated network, clinical data for patients may be siloed in disparate EHRs. Also absent from patient records are numerous other key pieces of information such as:

  • Claims data (e.g. services obtained, medications, etc)
  • Care plans
  • Lab results
  • Patient outreach information
  • Patient submitted / supplied information (biometrics, logs/journals, preferences, etc.)
  • Predictive analytics such as a readmissions risk score, clinical risk, forecasted cost, etc.
  • Analytics that measure medication compliance
  • Gaps in care/quality measures that need to be closed
  • Important non-clinical information (e.g. patient motivation, family support team members, life events such as a recently deceased spouse, and other social factors)

Enriching the patient record with this information enables a depth of patient understanding required to support the transformation to value-based care. Here are a few examples of how the enriched patient record can have an impact.

Scenario 1

With pharmacy benefits claims data automatically augmenting the patient record, a care manager can quickly see which prescriptions have been filled without having to log into multiple systems. They can complete a medication review faster and more accurately and can share this with the care team. It is well known that improper or inadequate medication management can  play a major factor in readmissions and complications (shown to cause as much as 20 percent of hospital readmissions[1]). However, having just EHR based medications (list or prescriptions) and pharmacy benefit / fill data is not enough. Being able to capture what the patient is actually taking can provide enhanced insight.  After medication review, a care manager can determine that a pharmacist needs to be added to the care team to help manage dosing regimens and timing of medications. The care manager can then assign a task to the appropriate care team member working at top of license to make arrangements with the pharmacist and add a note to the patient record that is shared with all other care team members. 

While completing medication review, a care manager may also discover life events that are barriers to medication compliance such as an inability to pay for medications, not having transportation to pick them up, or patterns such as sharing/splitting doses with a spouse. The care manager can then assign a task to an appropriate care team member to make transportation services arrangements for the patient or enroll them in an financial assistance program, and add another note to the patient record that is shared with all other care team members. 

Scenario 2

The same high-risk patient described above goes to see a primary care physician who is part of a clinically integrated network. When the physician looks up the patient’s record in their own EHR, the enriched longitudinal information and actions taken in Scenario 1 are carried forward to the point of care. In this scenario, the physician or nurse can have a deeper and more informed conversation with the patient about medication compliance. Furthermore, easy access to a  comprehensive, validated medication review as part of the enriched longitudinal record, can help speed up the medication reconciliation process in the clinic. With full context on the patient that also includes all care programs they are enrolled in, lab results, visits history, readmissions risk score and relevant patient documents such as a care plan, the provider is better equipped to evaluate and direct additional care. Simultaneously, the provider can also see gaps in care and quality measures (e.g. need for a depression screening) that can be closed while the patient is still in the clinic. From a patient perspective, the provider’s enhanced understanding of issues and plan of care can improve the overall experience. The physician can even see what motivates the patient (perhaps the care manager noted that the patient has a goal to be able to attend their grand daughter’s college graduation) and encourage continued participation.

In the big picture, successful population health management requires addressing a population of patients as individuals. An enriched longitudinal patient record as described here can help providers gain a better understanding of their patients and enable the care team to be more effective, efficient, coordinated and patient-centered.

To learn more about how your organization can obtain and share a longitudinal patient record across a care team, send us a note here to schedule a discussion. 



[1] Guitierrez, David. “Drug Side Effects Blamed for 20 Percent of Hospital Readmissions.” Posted from http://www.naturalnews.com/027866_drugs_side_effects.html# 1.4.10.

 

 

The Future of Healthcare: Innovating Coordinated Care


Post by Scott McLeod


Director of Product Marketing, Caradigm

One of the most impactful developments in healthcare today is the movement towards coordinated care. It’s essential as more healthcare organizations engage in population health management and participate in a broader health network with a variety of partner providers. Many providers have recognized that the care of a high-risk patient is a team-based activity that requires the coordination of a variety of clinicians and care givers serving different roles. It also involves a series of processes – intake, screening, assessment, developing a plan of care, reviewing a plan of care, making contact with care givers, reviewing medications, etc. To deliver the best patient outcomes possible, providers need to ensure that these processes are being completed efficiently and consistently across the team.  

The idea of coordinated care is not new, but being able to deliver it effectively is starting to become a reality as new health IT emerges to help enable it. A care team is made up of a diverse group of clinicians and family members that can include primary care physicians, specialists, a lead case manager, an in-patient case manager, a field coordinator that works on non-clinical tasks, a pharmacist, community organizations, and family and friends that may be providing support such as transportation or helping pick up medications. That’s a lot of people and a lot of information that is needed to properly care for just a single patient. Multiply that by potentially thousands of patients in a care management program, and it becomes clear why coordination and efficiency can be challenging.

Here’s how health IT can innovate care coordination. First, it brings together all the data and information needed to care for a patient from all systems across the health network. All care givers have a 360 degree view of the patient that includes the plan of care, medications, lab results, vitals, documents, immunizations etc. When an update is made, all care givers have that update in real-time. With a full 360 degree view of patients, the care team can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient-centered care by incorporating patient personalized goals.

Second, it transforms the efficiency of clinician workflows, which leads to increased productivity and consistency of care. Physicians can see care gaps and close them while still in the presence of a patient. Care plans, task lists and interventions can be automatically generated from the patient’s clinical information and assessment responses. Complete medication histories can be brought into single patient views that display order and fill history for easier review. Patients that may need immediate attention can also be tracked across the continuum through event-based alerts (e.g. admissions, discharges or Bluetooth device alerts). Lastly, all of the needed tasks are being assigned to the right team members assuring “top of license” activity.  

From the patients’ perspective, they’re on a better path to become healthier as they receive care focused on wellness and preventive measures. They’ll also receive a better patient experience as they don’t have to repeat answers and all care givers are up-to-date on their information. Care coordination is one of the foundational strategies healthcare organizations must employ to achieve the Institute for Healthcare (IHI) Triple Aim of 1) Improving the patient experience 2) Improving the health of populations and 3) Lowering the per capita cost of care. With a little help from innovative new health IT, coordinated care can become a reality.

The Importance of Patient Motivation in Population Health Management


Post by Steve Shihadeh


Chief Commercial Officer, Caradigm

As healthcare organizations take on more financial risk for patient populations, they must gain a much deeper understanding of their patient population in order to drive better outcomes. Realizing the full potential of population health management is limited by finite care management resources as well as each patient’s willingness to participate in his or her own outcomes. By stratifying your patient population based upon predicted future risk that considers patient motivation, providers can identify and prioritize patients most likely to be positively impacted by targeted care planning and interventions.

Factoring patient motivation into the risk stratification of a patient population is one of the exciting ways that Caradigm is helping innovate population health management. Consider the following example of two patients that I have a deep understanding of – my mom and my dad.  Both have chronic conditions, and would be identified by most providers as patients that are high risk or could potentially move to a high risk stratification. Inside of an EMR, the two patients look very similar, but the truth is they should be viewed very differently by providers.

My mom is the ideal patient. She follows her physician’s instructions, fills her prescriptions promptly, schedules her follow-ups, and takes exercise classes as recommended. On the other hand, my dad presents as a more problematic patient because he doesn’t follow his doctor’s recommendations. He’s the opposite of my mom in terms of participating in self-care even though he also has a chronic condition that needs ongoing management.

For a provider, it is extremely valuable to factor in patient motivation when stratifying populations to identify and prioritize patients like my parents. Providers are more likely to have much better outcomes from interventions with motivated patients. Care teams can better assess which patients will benefit most from certain types of interventions, so that they can manage their limited time in order to receive the highest return on intervention.  I am not saying “only focus on motivated patients” but I am saying “working with motivated patients can have the biggest positive impact for all”.

I have been asked, “How in the world do you measure patient motivation?” It starts with being able to aggregate and leverage all of a provider’s data (e.g. clinical, claims, financial). Next, Caradigm applies sophisticated analytics to that data with help of our partner LexisNexis with MEDai Science who has been refining and perfecting the accuracy of how they calculate patient motivation for many years. The data plus analytics then enables deep population stratification and providers can use that information to streamline care management workflows as well as surface it at the point-of-care to guide decisions.

I’ll be participating on the Data Analytics and Practical Uses panel at the Becker’s Hospital Review CEO Strategy Roundtable on November 4th in Chicago, and would happy to continue the discussion at the event or after.

Why Care Managers Should Be Excited About Population Health Management


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

Patient care is part science (i.e. tests, treatment) and part art (i.e. communication, motivation, prioritization). Today, effective population health solutions can link the science and the art in a game-changing way that will help care managers deliver better care, more efficiently.

Care managers are asked to do a lot. The typical care manager at a large hospital network has a full case load, which limits the ability to deliver quality care across a population. The reality is that we’re not going to have enough care managers to care for the growing number of patients, so we have to become more efficient. We also need to empower motivated patients to manage their own care.

Caradigm® Care Management was developed in partnership with Geisinger Health Plan based on extensive observations of their care management team. Together, we came to the conclusion that what care managers needed most was to 1) have complete data and analytics in a single workspace and embedded into workflows and 2) automate routine processes. Here are just a few examples of how a care manager’s life can be made easier:

  • Task lists and interventions are automatically generated from assessment responses that list the top interventions needed to get the highest risk patients to a better place and assure consistent work practice.
  • Complete medication histories can be brought into single patient views that display order history and fill history for easy review.
  • High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).
  • With a full 360 degree view of patients, care managers can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient centered care by incorporating patient personalized goals into care plans.
  • Patient workloads or specific tasks can be reallocated to other care managers or support staff, assuring “top of license” activity.
  • Best practices of care managers can be identified and then shared across the team.

This is exciting, transformational change. Care managers today are hunting down information from many systems and storing that information all over the place on sticky notes, notebooks, applications, and then must synthesize that into a care plan. Multiply that by 50, by 100, by 200 patients, and it’s challenging to do it efficiently. Caradigm’s population health management solutions are transforming care management, and I am thrilled to be part of the journey.