Guest Blog: Better Care at Lower Cost for People with Multiple Health and Social Needs

In my role at Lumeris I often get asked by our clients, “What does care management really mean?”  For me, having spent decades practicing geriatric medicine and teaching the principles of post-acute care coordination at a private research university and medical center, care management can be defined, most completely, as better care at lower cost for people with multiple health and social needs.

I know firsthand the challenges physicians face in providing quality care to high-risk patients and populations. It is hard to believe that better outcomes can be achieved when nationally, re-admission rates remain close to 24 percent within 30 days of hospital discharge, and nearly 80 percent of these readmissions are for preventable conditions according to MedPAC.

To achieve better care at lower cost, health systems need to change the way they manage high-risk patients and create an entire care community working together to ensure that each patient receives the right care, in the right place, at the right time.

Though that sounds like a far-off health care utopia, I have worked closely with Lumeris at designing a Care Management solution that achieves what may seem impossible.  The results of this solution speak for themselves in the Lumeris-operated 4.5 star-rated* Medicare Advantage Plan where health plan staff, physicians and patients have worked together to reduce 30-day hospital readmissions by nearly 13 percent in 2012.

This Care Management solution supports multiple workflows in the coordination of care for high-risk patients and high-risk events. Technology, education and strategy support the health care team in their ability to effectively stratify, engage and manage high-risk patients and populations to prevent adverse health outcomes, while managing cost and delivering optimal patient care.

Specifically, the Lumeris Care Management solution provides:

  • Complex Care Management – a solution that can be targeted for disease-specific programs and the identification of gaps in care as well as high-cost and high-risk members. This solution identifies and stratifies populations with multiple care needs, launches disease-specific management campaigns and enhances communication among team members.
  • Transitions in Care – is focused on the high-risk time period following hospital discharge to other care settings in order to prevent adverse outcomes, such as hospital readmissions. Easy patient identification and evaluation of at-risk patients enables the   care manager to create a custom, symptom-response care plan and a detailed care plan that can be shared with and acted on by patients.

*Plan performance star ratings are assessed each year and may change from one year to the next.

  • Medication Management – is designed to enable the effective use of medications by improving adherence, reducing polypharmacy and helping identify high-risk drugs for patients with chronic disease.  Medication management can help reduce the 60 percent of hospital readmissions that are related to medication non-adhearance, misuse or medication mistakes.
  • Patient Engagement Training – trains clinicians through interactive sessions of motivational interviewing to involve patients in their own care management. This shift in a practice’s focus to primary care and population health requires greater involvement of the health care team, with the most important member being the patient.
  • Advance Care Planning – provides the tools to facilitate the conversation about disease progression and the needed next steps for the transition to end-of-life care such as symptom management and defining goals of care.

With a comprehensive approach to Care Management, health systems can manage their high-risk patients and populations and achieve the Triple Aim Plus One: improved clinical outcomes, lower costs and enhanced patient plus provider satisfaction.