Care Management in Action: Stories from the Field

Mary Ellen Cross Health Plan and Provider Relations, News, Population Health Management

care management

What is the Care Management Model?

As the health care industry moves toward a value-based reimbursement model, care management is increasingly being deployed to drive improvements in care coordination, patient education, and social determinants of health. Care management can take many forms, from telephonic contact with a patient to face-to-face interactions. One of the most important elements of a successful care management model is a team-based approach.

At Medical Advantage Group, our model includes care managers who are embedded within the primary care practice collaborating with a specialized group of their peers on a centralized team. The specialized team includes a behavioral health therapist, a registered dietitian, and a pharmacist who combine their knowledge and talents to meet the complex needs of their patients. The team is rounded out by a panel manager who identifies high-risk patients and a care coordinator who reaches out telephonically to patients transitioning from hospital to home or an extended care facility.

“…Care Managers are improving the lives of the people they serve and improving the quality of care at the physician practices they support. Care management shows the power of teamwork and collaboration in meeting the needs of patients. By looking beyond the numbers, we can see the positive impact these professionals have on the lives of patients.”

The benefits of care management are well-documented and include improved quality scores, reduced readmission rates, and a positive patient experience. When we look at outcomes, it is easy to just focus on the numbers. It is important to remember that every numerator and denominator in a quality measure represents an actual person. In this article, we’ll take you beyond the numbers and share some real-life stories that demonstrate the value of care management and teamwork.

Obtaining Needed Meds for a Patient Avoids Readmission

Emma* was at home recovering from an acute admission for cellulitis when she received a post-discharge follow up call from Jessica, Medical Advantage Group’s care coordinator. During their conversation, Jessica learned that Emma was only dispensed a partial dose of the antibiotic used to treat her infection and that she would be without medication by the weekend.

Apparently, the discharging facility had failed to obtain a prior authorization for the drug. Jessica immediately recognized the potential risk to the patient and referred the case to the pharmacist on the centralized team. Receiving this referral late on a Friday afternoon, pharmacist Rachel knew that she needed to work quickly.

What followed was a series of calls to Emma’s health plan, primary care physician, and Emma’s pharmacy. Rachel was able to obtain a prior authorization and have the remainder of the dose in the patient’s hands before a single dose was missed. In addition, Rachel referred Emma to her physician’s embedded care manager who arranged to see Emma during her visit the following week for proper follow up and education. Intervention by Medical Advantage Group’s care management team helped Emma get the care she needed and avoided a possible readmission to the hospital.

Referral to a Dietician Helps to Manage an Uncontrolled Diabetic Patient

Melinda* was an uncontrolled diabetic with an elevated Hemoglobin A1c level. Dan, the panel manager at Medical Advantage Group noticed Melinda’s case on his monthly list of high-risk patients. He contacted the embedded care manager at the practice, and they both agreed that Melinda would benefit from a referral to a registered dietician. When Dan discussed this with Melinda, she was open to the idea, especially because this dietitian would meet with her in the familiar environment of her physician’s office.

When Melinda began meeting with Jon, Medical Advantage Group’s registered dietician, she felt reluctant and a bit hopeless. She was overweight and refused to get on a scale. Jon began by discussing Melinda’s goals regarding her weight and health. He collected information about her eating habits and health history. By the end of the first appointment Melinda was able to see that Jon was on her side and was invested in helping her achieve her health goals.

Together they developed a plan for her diet, and she began to monitor her weight. After working with Jon for three months, Melinda had lost 40 pounds and her Hemoglobin A1c level had dropped to a near-normal range. Jon was able to provide education about her condition to help Melinda with ongoing self-management of her diabetes.

Advocacy Helps Patient with Chronic Depression and Anxiety Find Healing

Sarah* was struggling with depression and anxiety. She was referred to Alisha, Medical Advantage Group’s behavioral health therapist, by the embedded care manager at her physician’s office. It became clear during their therapy sessions that Sarah’s anti-depressant medication was simply not working. Sarah had been faithfully attending her primary care visits and engaging in therapy twice a month, but her depression just seemed to be getting worse. Alisha had attempted to coach Sarah in discussing a medication change with her primary care physician, but somehow there was a disconnect and the conversation never occurred.

Alisha consulted with Rachel, Medical Advantage Group’s pharmacist, who agreed that the medication regimen should be changed. Recognizing that Sarah was unable to have this conversation with her primary care physician on her own, Alisha offered to go with Sarah to her next visit. During the appointment Sarah, Alisha, and her physician thoroughly discussed Sarah’s needs, concerns, and the care team’s recommendations. Sarah’s physician agreed that it was time to make a change. With her new medication regimen and regular therapy, Sarah has had some relief from her symptoms and is happy to report an improvement in her overall outlook and quality of life.

Health Care Managers Improve Quality of Care

Day in and day out, care managers are making a difference. They are improving the lives of the people they serve and improving the quality of care at the physician practices they support. Care management shows the power of teamwork and collaboration in meeting the needs of patients. By looking beyond the numbers, we can see the positive impact these professionals have on the lives of patients.

*Names of all patients in these stories have been changed to protect their privacy.


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