Care Management: Ensuring Successful Care Management


January / February 2006

Care Management

Ensuring Successful Care Management

The healthcare industry is facing a multitude of challenges. An aging population, clinical staff shortages, ongoing medical advancements, increased consumer demand for information, and a growing number of people living with chronic diseases are causing healthcare stakeholders to re-evaluate the way they view healthcare. Better collaboration across the entire healthcare spectrum — payers, providers, and members/patients — is one way to address these issues and ensure successful care management in the future.

Facilitating across-the-board collaboration requires the use of automated systems to connect all constituents and provide the right information at the right time to the right audience. Although it is not the only success factor, uniting the human element with technology greatly increases the success of care management programs.

Currently, a greater push for integrated care management between payers and providers exists. These parties are consistently updating and improving their care management and automation technologies. The heightened focus on Medicare/Medicaid reform and need for electronic health records (EHR) will help accelerate the transformation to a more collaborative model.

How Will It Work?
Successful care management programs should be designed to encourage strong payer to member, member to provider, payer to physician, and physician to member relationships — allowing for a more holistic approach to care (Figure 1).

Patient Safety and Quality Healthcare

A holistic view examines the patient’s overall health versus focusing solely on “incidents.” It considers what has happened in the past while predicting what future outcomes may be and requires integration across the healthcare spectrum to understand the complete picture. Achieving truly integrated and holistic care management requires collaboration at all levels, combined with the use of technology, including:


  • Patient risk screening
  • Disease management
  • Alternate encounters (such as RN clinics, team visits, group visits, home visits)
  • Team-based care
  • Cross-continuum coordination
  • Outreach
  • Population screening and analysis
  • Patient enrollment
  • Guidelines/protocols (including wellness and prevention)
  • Point of care
  • Patient empowerment


Implementing an integrated care management system will strengthen the link between preventative management, disease management, and information integration to better contain costs and improve patient outcomes.

Typical elements of an integrated care management system include automatic alerts and features to notify the manager if the member needs immediate intervention. The optimal model will empower the member through online education, enhanced communication with the care manager, and other benefits.

A Web-based component within such an integrated system allows for more direct communication about sensitive issues. For instance, it can be difficult for a physician to set aside an appointment time to talk to a patient about weight management matters. But with relevant information readily available on the Web — and the physician directing the patient to take advantage of it — the patient can learn more about his health and ways to manage it. This is an easier and more direct way to address sensitive issues such as weight loss.

The key to creating information a care manager can use is to interface pertinent data from other systems. For example, the core system can provide information on eligibility, provider, authorizations, claims, pharmacy, and immunizations, while other sources might provide information on member services, underwriting, health risk assessments, and decision support.

Rather than being bogged down with information repeated in multiple sites, the optimal method for data sharing is to link the care manager to data sources in external systems. Elements such as lab reports, medical records, notes from a home health agency, and scanned documents can all be accessed via secure links on the Web. Built-in security features can eliminate the possibility of data falling into the wrong hands.

Technology now exists for care management systems to monitor patients and trigger alerts to care managers if a patient isn’t complying with the prescribed course of treatment or if there are other factors that might trigger deterioration in health.

The Constituents
Truly successful care management will help stem the rising costs associated with care and bridge the communication gap between providers and patients — in ways both mundane and profound. The greatest opportunity to improve care management comes through the collaboration efforts of the various healthcare constituencies linked through technology. While technology can be used to improve routine office matters, it also can be used to strengthen and improve the payer-doctor-patient relationship. For example, the Internet has revolutionized patient/provider interaction. Physicians and other providers need to be able to respond differently than they did 10 to 15 years ago, because patients have much more information at their fingertips through sources such as Web portals and discussion groups. It’s estimated that the number of health plan members who actively take advantage of “personalized” health portals has increased by the millions over the past year.

The perspectives of each party are important in understanding the significance of implementing care management systems.

The Payer Perspective
Technology offers payers many opportunities for strengthening collaboration with other healthcare constituents and ultimately helps reduce costs and improve patient outcomes. Additionally, care management tools help payers manage patient data more easily and integrate it better with clinical and financial data on behalf of providers, subscribers, and patients.

Payers use a vast amount of information including data on member utilization patterns, member financial data, clinical claims data, outcomes data, and more. Underwriters create massive amounts of data as they identify and quantify that risk on prospective subscriber populations. Since payers have a plethora of information to manage, it’s not surprising this segment is leading the care management charge, with at least 99% of them providing some form of care management program.

Additionally, their customer base is in a constant state of flux. With such frequent changes in plan membership, payers say most members will “re-present” in plans they’ve left previously — often multiple times over the years. Therefore, it is important that strong programs are in place to provide a continuum of care for all members. With greater collaboration, the patient is more likely to receive a continuum of care and improved outcomes.

Another key reason why care management is significant and why payers see care management programs as critical offerings is the aging U.S. population. Older members typically require more services and can benefit most from care management programs.

The Provider Perspective
Increased availability of information and changes in technology have revolutionized how patients interact with their providers — upping the ante for providers in terms of care management and patient education. Consumerism is having a profound influence in patients. For example, a patient may see an advertisement on television for a certain prescription drug and then ask his provider whether that medication would work for his symptoms. Providers often struggle with what care management programs require in terms of patient demands and program outcomes.

While consumer marketing is an impetus for a patient to demand a new course of treatment, easy access to critical information and a complete personal medical history through the implementation of an EHR — as well as information on clinical trails and drug interactions — can help a doctor better explain why a particular course of treatment may or may not be in the patient’s best interest. The healthcare system today is not structured for providers to be educators. Time constraints, heavy patient loads, and expenses have served to decrease the amount of face time most providers spend with patients.

The Patient Perspective
With the rising cost of healthcare being transferred to patients, it is important for patients to look for ways to take an active role in their own care and hold providers more accountable for improving outcomes. With increased access to care come opportunities for everyone in the healthcare continuum to be more involved at all levels. By regularly accessing health and wellness information, potentially through the implementation of an EHR, patients will remain healthier through self-monitoring, will require less time being educated in person by caregivers, and will increase quality of life by decreasing the need for acute services.

Members can work collaboratively with care managers through the Web to access materials, communicate on an ongoing basis, complete health risk assessments, and conduct other activities. By regularly accessing health and wellness information, patients will remain healthier through self monitoring, will understand and engage in healthier lifestyles, will require less time being educated in person by caregivers, and will increase quality of life by decreasing the need for acute services. Providers can facilitate this process by using secure portals on the Web to review and sign off on care management plans, receive alerts from care managers, and offer up specialized programs and information for their patients such as weight control guidelines.

Future Outcome?
The surest way to increase patient satisfaction is to keep patients healthy. Over the next decade, improved care management — enabled by technologies designed to aid in preventative care, patient education, and predictive modeling — will offer U.S. healthcare more creative and intuitive methods to achieve patient satisfaction; improve collaboration among payers, providers, patients, and care managers; and realize cost savings.

Mark Roman is the global leader of EDS’ Healthcare Industry practice, which provides healthcare solutions including an advanced care management system, EDS ATLANTES, and the MetaVance administration and finance system. With a 22-year career in consulting and business process improvement, Roman has extensive industry knowledge and experience in the provider, payer, life sciences, and government health segments.