Insight to Action

Could Your Care Management Program Be Doing More?

13 January 2017

So you’ve committed to a data-driven approach to managing your employees’ health and wellness. That’s great. But don’t get complacent. You need to continually measure your progress and make sure your program is delivering on your objectives. If it isn’t measuring up, you may need to correct course.

Take the example of Montefiore Health System in New York. Back in 2011, Cammack Health’s annual Hospital Survey revealed that Montefiore’s per-employee, per-year (PEPY) health plan expenses and utilization were above those of its peers. Faced with this data, Montefiore Human Resources management recognized the need to reverse this trend. Rather than simply shifting costs to employees, they were determined to target the underlying factors driving cost and utilization.

Fortunately, they didn’t have to start from scratch. Montefiore already had a well-established, data-driven care management organization (CMO). Building on this foundation, we worked closely with CMO and Human Resources to develop a new Care Guidance Program designed to achieve a few key objectives:

  • Educate and encourage members and their dependents to make healthy choices.
  • Identify and engage members at risk and guide them to appropriate wellness programs.
  • Help members with significant health issues navigate the healthcare system to help improve treatment plan compliance.
  • Reduce costs by improving health trends and by encouraging members to seek care within the Montefiore Health System whenever possible.

Achieving these goals meant addressing care management from every angle—from providing members with health education, care coordination and disease management on an opt-in basis to engaging providers to make them aware of the program and to support their treatment plans.

Assembling the right team of professionals was a priority. The Care Guidance Program is staffed by a multidisciplinary team of RNs and LPNs serving as Personal Health Nurses (PHNs), supported by a pharmacist and nutritionist, all trained in care management techniques. The PHNs work directly with members to guide them to appropriate health resources and promote healthy behaviors and treatment compliance.

Data also played a key role. The CMO team analyzes a wide range of metrics to identify members with health risks, such as poor utilization records, high predicted costs, out-of-range lab results, or non-compliance with EBM guidelines. Since numbers often don’t tell the whole story, rigorous subjective analyses complement these objective measures.

What was the impact of all this? Within just two years of launching the Care Guidance Program, Montefiore saw trends moving in the right direction. PEPY costs were reduced by more than $1,000, bringing it below the benchmark for Montefiore’s New York hospital peers. Claims costs and utilization were reduced. In-system utilization was up, as was use of generic medications—addressing two key cost drivers. Just as important, medical compliance with key diabetic measures was improved for participating members.

One of the most important lessons that can be drawn from the Montefiore experience is that care management isn’t a “destination” but a “journey.” Continuous assessment and improvement is crucial to ensure your institution—and its health plan members—are receiving the greatest benefit from your care management investment. How is your program doing?