Heather Lavoie, Geneia Chief Strategy Officer
The advent of value-based care has changed the nature of care management. Today’s care managers are responsible for larger caseloads that include more than chronically-ill members. In addition to working with these members, care managers are charged with identifying and engaging healthy and rising-risk members and ensuring quality measures are addressed for the entire population.
Enter the Theon® Platform for Cost and Quality Improvement Analytics (Theon® Platform) built on Salesforce Health Cloud.
Let’s take a closer look at how Judy*, a health plan care manager, uses the Theon® platform for Health Cloud to improve her member engagement rates, utilization and costs of her patient population, and quality measure performance.
To be successful and engage members based on their individual needs, Judy needs to identify and stratify her patients into categories of:
• Chronically ill and
• Catastrophically ill
Using the Theon® platform built on Health Cloud, Judy easily views the entire population of patients for which she’s providing care management services. She is particularly interested in patients with rising risk. To identify those patients, Judy looks at:
• Future cost,
• Prospective or future risk score,
• Retrospective demographic risk and
• Total cost
Together, these point to a list of members with rising risk.
She sees Charles Green towards the top of her list of rising-risk members. His current costs are just over $24,000, but his future costs are projected to jump to nearly $47,000, and his prospective risk score is more than four.
The Theon® platform built on Health Cloud integrates medical and pharmacy claims information with the clinical record. All in one view, Judy sees Charles’:
• Utilization in the form of doctor visits,
• Emergency department visits and hospitalizations,
• Open care opportunities, risk trending and risk score,
• Insight into his future costs and his future risk for additional hospitalizations and
Closing Care Gaps
As a care manager working with providers in value-based arrangements, Judy has to be mindful of the open care opportunities across her patient population and then work to close those gaps for individual patients. In the patient discovery screen, she views Charles’ open care opportunities, including comprehensive diabetes care and controlling high blood pressure. By helping to close them, she may in turn help Charles address his rising risk score.
Given Charles’ level of risk and open care opportunities, Judy can help keep him on track reminding him often and checking in on him to make sure his blood pressure is within range, his weight is in check, and his blood glucose readings are stable.
For Charles, regular surveillance of his biometric data through remote patient monitoring or a health kiosk at his grocery store or pharmacy allows data to be sent back through Health Cloud and into the Theon® platform. Automatically, Charles’ open care gaps are closed, his risk scores updated, and Judy’s task list is updated as well.
As a care manager in a payer organization, Judy was able to help them improve 19 of the 25 key quality measures that are a part of their value-based contracts as well as improve utilization and cost across the most pertinent areas.
Not only was Judy able to help improve the care for her patients like Charles Green and improve the quality and cost of the population for which she is accountable, but by using the Theon® platform built on Health Cloud, she is able to do so in a manner that makes population health scalable, relieves physicians of the burden, and helps to restore the Joy of Medicine.
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* Judy and Charles Green are fictional and not intended to represent any specific persons. This information is provided for illustrative purposes only.
Geneia LLC is a healthcare analytic solutions and services company that focuses on improving systems to support personalized, patient-centered care. We help clients improve outcomes, lower costs and restore the Joy of Medicine to physician practice. Our technology, education and training, insights and clinical services simplify the evolution to value-based care and drive alignment and collaboration among healthcare providers, health plans and employers. The company has offices in Harrisburg, PA and Manchester, NH. To learn more, visit Geneia.com (https://www.geneia.com) or connect with us on Twitter and LinkedIn.