by Webmaster, PhoenixMed
Published on Nov 21, 2016

What if a high-needs patient, such as a stroke plus any rehab and follow-up care, is considered a single episode of care to be managed smoothly and seamlessly from start to finish across care settings? This is the future of care management. Are you ready?


As the focus on population health and care coordination across the continuum has increased, hospital case management programs have been unexpectedly thrust into the spotlight. Care coordination across the continuum implies a whole different orientation to care management than many of the present hospital case management models. More than 50% of hospital based programs are still functional; they position care managers as discharge planners and many still burden that same care manager with utilzation review activities despite growing evidence of the need for expert knowledge of the regulatory underpining of a successful revenue cycle process.

We recognize that each hospital is in a different place on its path to care coordination across the continuum and with this in mind, we have developed a guide to help any organization begin the journey.

1. Create a future vision, define the model and establish goals to measure sucess. 

Before leaders can take a chance on an innovative idea and invest resources into building a new program, they must achieve consensus on a vision defining the intent of a future program. This is an essential component to make sure executive, medical, and the clinical associates understand the future trajectory of the program and the innovations to care delivery.

Next, the organization must establish specific, measurable goals that will demonstrate the success of the care management program.  The goals must be clearly communiated to everyone on the care management team - inpatient, transitional care, community care - to promote allignment toward a common mission. 

2.  Create and prioritize a resource investment strategy

Once intent and goals are established, leaders can strategize how to allocate and coordinate resources to meet the desired goals. Leadership must consider how funds and resources will be allocated across 5 key components of a continuum of care program:  Care management workforce, care management platform, analytics, post acute outreach, and target populations.  

3.  Patient selection

Estimates of high severity inpatients range from 10% to 28% and account for less than 15% of all beneficiaries. Among these high-cost beneficiaries, virtually all have multiple physical and behavioral health conditions .  Due to their complex health needs and the liklihood of obstacles they encounter throughout the continuum, it is essential that they have care coordinators who can address clinical and non-clinical needs. For example, efficiencies and effectiveness of inpatient progression-of-care must be supported by a care manager working collaboratively with the patient's care team to expedite care, promote evidence based care and to smooth transitions of care.  In addition, the care manager must identify services that their patients might need to safely move back to the community including transitional care services, socioeconomic gaps, and non-professional community care coaches.

4.  Manage at-risk and high risk  patients across the continuum   

At risk patients need special attention beginning in the hospital, to keep from becoming high risk patients;  and high risk patients need special attention by a dedicated care manager responsible for assembling a care team to address the patient's on-going needs and maintain caregiver engagement across the continuum. 

5. Identify low risk patients and develop programs to keep them informed and well. 

Within every patient population covered by an at-risk contract, there are low risk patients with health needs that must be monitored regularly to control effectively and prevent escalation: e.g. hypertension, diabetes,arthritis, et al. Care management services must be organized to inform, educate, and monitor these patient regularly and offer preventive interventions and low-acuity care options to avoid this population from moving into high risk component. By offering this service, a comprehensive care mangement program has the potential for revenue generation from small business and other employers who are self insured or under risk bearing contracts.  

Creating a care coordination program across the continuum not only benefits patients, communities and organizations, but also helps providers maintain good standing under new payment models.  Although the transformation process from a tradtional hospital case management program to a continuum-of-care program is lengthy and may require new investments, hospitals cannot afford to put it on the backburner. By thoroughly going through each of these steps, case management leaders can make innovation possible.