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Next Frontier of Care Management

by Matt Guldin | March 31, 2017


As we wrap up the forthcoming 2017 Care Management Market Trends Report, I have been pondering the issue of social determinants of health (SDoH). In our HIMSS Conference 2017 recap, we noted that SDoH “came across as an unexpectedly strong conference theme — though, again, we saw only random application of functional use cases.”

Since then, the broader market interest and momentum around SDoH has continued to build, as it has come up in several conversations and vendors’ demos . What we are finding, though, is well-stated in this quote from an HFMA article by Ninon Lewis, an executive director at the Institute for Healthcare Improvement (IHI):

“What we’re finding is that many communities are resource-rich and coordination-poor. That’s what healthcare organizations have to realize-the resources they can tap into are much more broad than what’s within the walls of the healthcare delivery system. That’s the next frontier for healthcare organizations. It’s both the challenge and the beauty of the opportunity-there are a lot of hands in the community to help serve the needs of the populations they care for, and the key is knowing where they are, developing the skills to collaborate with new partners, and find the means to pay for addressing the social determinants of health.”

Healthcare organization (HCOs) are forming new cross-sector partnerships to meet both the medical and social needs of the populations they serve, including Medicaid. Development of these relatively new, cross-sector relationships is happening under a variety of partnership models. Before partnering with a community or social service organizations, there are a few important items for an HCO to consider:

  • Organizational traits of the community or social organization, including its governance, business strategy, marketing expertise, current financial condition and financial controls, access to capital for expansion, and leadership and management competencies.
  • Partnership mechanisms, including any formal or informal agreements.
  • Efficient workflows between the organizations to ensure that patient needs are addressed with minimal disruption to both organizations and their workforces.
  • IT infrastructure to share patient information and coordinate care, as well as facilitate client billing.
  • Monitoring capacity to measure partnership success through systems that collect, organize, and measure data about various process and outcomes-based metrics.
  • Sustainable financing models such as per-service payments, Medicaid reimbursement, and shared risk arrangements.

On the HCO side, some of the responsibility to operationalize these partnerships on behalf of their patient populations may be delegated to core care team members, such as PCPs, NPs/PAs, or medical assistants. This is especially true if a more formalized primary care strategy such as an advanced medical home model is in place.

This tends to be limited, though. HCOs typically delegate these responsibilities to several different types of individuals on the extended care team: Care navigators/care coordinators, social workers, community health workers, and even community paramedics. Some of this responsibility may also be placed on the nurse care manager if the types of aforementioned extended care team members are not available or in limited capacity.

While coordinating with community and social services stakeholders around transportation, food banks, housing, and so on is a growing concern for HCOs, the IT infrastructure to support workflow requirements and monitor capacity is almost nonexistent. These functionalities are completely absent from EHRs, and the vast majority of the care management solutions in the market do not provide the functionality to integrate them directly into the nurse care manager or care navigator’s workflow. HCOs often rely upon an individual’s experience, including knowledge of locally available community and social resources and a manual workaround process involving phone, fax, and even paper-based referrals.

If HCOs are going to move to more capitated models of valued-based payments, it will be critical to cover broader parts of the population they serve, and to readily form and scale the partnerships with various community and social stakeholders. Health IT solutions will play a critical role in helping HCOs achieve this – even if we are just starting to see these solutions emerge in the market or as care management and care coordination vendors start to include elements of this functionality in their solutions over the next year or two.

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