Patient Care Management Standards for Outreach and Graduation: The Fifth Attribute in a Modern Care Management Model

by Tomi Ogundimu on Sep 18, 2019

Patient OutreachTo understand how their organization enrolls and conducts outreach to patients entering a care management program, care coordinators often find themselves questioning procedures:     

  • What is our process to enroll our patients?
  • How do I get them activated in their care?
  • How do I persuade them to willingly work with us?

Obviously, patient engagement is the crucial factor to the success of any care management program. Many healthcare providers, however, miss one of the key milestones for maximizing patient participation—and it starts at enrollment.

The following concludes a series of blogs from the Advisory Board's Tomi Ogundimu in partnership with Ensocare. You can read Part 4 here.

Three Challenges to Enrolling Patients Effectively

The first of three key challenges to enrolling patients effectively into care management is the identification of candidates.

Since some providers lack sophisticated population health management strategies to identify potential patient enrollees, their recruitment approaches tend to be reactive. For example, a health system might select candidates based on those patients triggered through emergency department (ED) utilization resulting in hospital admissions.  

But by narrowing patient enrollment solely to reactive identification methods instead of proactively encompassing the broader population, administrators overlook countless opportunities beyond the ED to improve outcomes.

The second key challenge is that many providers tend to have minimal standardized processes and talking scripts to aid in informing and motivating patients entering care management programs. This is unfortunate, as a poorly defined set of program rules can create excessive workflows, inefficiencies and communication breakdowns.

The third challenge is that some organizations’ outreach efforts are limited to a “one-size-fits-all” program messaging approach. By failing to tailor your standard messaging to a patient’s specific health need or appealing to certain demographic groups, opportunities to fully engage interest are guaranteed to be lost. Without the right personalized introduction, enrollees at the onset are unable to comprehend the goal and role of a care management program.

Ensocare-Care Management Webinar 35Recommendations to Optimize Enrollment

Let’s review some proven recommendations to make your patient enrollment process fully effective as outlined in the following graphic.

Ensocare-Care Management Webinar 37The foundation of effective outreach and enrollment is establishing and communicating defined eligibility criteria for all target patient populations. Having easy-to-follow, explicit eligibility criteria that is widely shared makes the process easier for your clinicians, support staff and healthcare partners to refer the appropriate patients to the outreach team.

From that point, be prepared to pilot several types of outreach techniques such as in-person introductions and phone calls. It’s important for new care managers to receive training on program messaging and learn the locations to prospect patients—and even the appropriate number of times to solicit and win the patient’s buy-in.

Next, consider alternative types of care—or potentially good outreach touchpoints—for eligible patients to seek treatment. Within the clinic, complex care managers can coordinate with physicians or nurses to attend a co-visit to discuss the program and solicit patient enrollment in person, with the doctor’s encouragement. Within the inpatient setting, care managers can visit eligible patients at the bedside to promote the care management program.

Indeed, the hospitalized patient already is a captive audience. Care managers can receive real-time data indicating the admitted or seen patient is eligible for care management. Or, if care team members have a relationship with the inpatient staff, such as your bedside nurses, for example, they can notify complex care managers once an eligible patient is admitted. Similarly, hospital or clinic staff members who are discharging patients can alert them of the program and set up visits with administrators.

Last point: Program scripting, or messaging, is critically important. For Medicaid or uninsured patients, I recommend emphasizing that the program is a free service extended to them. Follow up by explaining that they did nothing wrong and were identified by their provider as possibly benefitting from additional care support to help manage daily needs. 

For the Medicare population, the primary reason to highlight participation in care management is the ease of receiving education through a single point of contact to coordinate all various needs and questions for providers across the system. If your organization manages a large employer group health plan or self-insured population, privacy is the most vital program component to emphasize while assuring the necessary care management support.   

Program graduation to self-management

Once the patient enrolls in a care management program, what ensues is an intense period of progressing patient management phases, including the changing of behaviors to meet care management plan goals. Ultimately, the care team’s support lessens to ready the patient for the formal post-graduation phase. The patient is now responsible for ongoing self-management in their own home.

Though this program period may seem intuitive, many organizations surprisingly lack clearly defined patient management phases. This oversight creates workflow challenges if patients are not advancing through these various stages. In fact, having a defined workflow simplifies your organization’s ability to work within the parameters of key functionalities and enables automated care management processes.

This illustration highlights the different aspects of the Advisory Board’s Best-In-Class Care Management Workflow.

Ensocare-Care Management Webinar 40Congratulations, Graduate!

Lastly, I must share an essential observation underscored by a multitude of frontline care management program staff: Setting up a graduation is a goal and an accomplishment that is important for the patient and serves as a good reminder for care managers. Understandably, care managers become emotionally invested while caring for their patients and vice versa.

With that said, the Advisory Board’s reassessment and redesign care management surveys reveal one of the largest and most important drivers of unsustainable workloads and caseloads is that provider organizations do not maintain explicit standards upholding a patient’s graduation. Nonetheless, some organizations have instituted other step-down support to ensure patients are truly ready for self-management before they graduate.

Ensocare-Care Management Webinar 42In this graphic, Gunderson Health System in La Crosse, Wisconsin, divided their patients into “active” and “monitoring” categories in order to create separate care management workflows. Active patients receive more intensive care during regular appointments. For patients who are improving regularly and who have learned to self-manage their conditions, their care managers check in every two months to monitor any decline, keeping track of their progress via an electronic medical record system. Ultimately, the most stable patients are discharged from the program. 

Bottom line: Gunderson Health System leaders’ action to shift self-managing patients to monitoring support maximized their care manager capacity and generated cost savings while looking ahead at patient care charges post enrollment.

This post concludes my five-blog series. To echo Luis Castillo, Ensocare’s President and CEO, though large-scale redesign of your modern care management model may seem like a never-ending process, rest assured that the ideal ROI is very much within reach: A healthier post-acute care population receiving the right longitudinal care services at the right time and at the right place.

Want more of Tomi's expert insights? View the "Getting the Most Out of Your Care Management Model" webinar now!

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Meet the Author

Tomi is the practice manager of Population Health Advisor, a custom project-based membership offering strategic guidance and best practices on the transition path toward population health management. In this capacity, she works with population health and care transformation leaders on a wide range of topics including developing an integrated care management model, measuring the ROI of their interventions, care delivery innovation, post-acute care network development, and patient engagement. Prior to joining the Advisory Board, Tomi worked as a health policy consultant for the Center for Healthcare Research and Transformation—a non-profit partnership of the University of Michigan and Blue Cross Blue Shield of Michigan—where she gained expertise in a range of health policy issues. Tomi graduated from Michigan State University with a bachelor of science in human biology and holds a master of public health in health management and policy from the University of Michigan.