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In this Business Profile, Scott Kolesar, principal and senior leader in Deloitte Consulting LLP's Value Based Care practice, and David Wennberg, MD, MPH, adjunct associate professor of The Dartmouth Institute and former chief executive officer, Northern New England Accountable Care Collaborative, discuss the challenges and competencies involved in creating a care management organization.

David WennbergCare management has become a key issue in the implementation of value based care. What should healthcare organizations keep in mind as they manage care?

David Wennberg: A key challenge is having healthcare organizations rethink what care management and coordination really are. They may have discharge planners, navigators, or even disease managers on staff, and in their minds that constitutes care management. In reality, these roles exist in silos. Staff members expedite acute care strategies, not improvements ?along a care continuum. Instead, I would define care management as patient-centric, longitudinal support that reduces the overuse of undervalued services and increases the use of effective interventions.

What are the core competencies required for successful care coordination?

Wennberg: What I would call the generalist model for care coordination requires three core competencies. The first competency is having the skill to navigate the healthcare continuum. Staff need to direct patients to the appropriate provider and setting for their care. The second competency is enabling behavior change. This means getting individuals engaged in behaviors that promote long-term health, such as stopping smoking, controlling blood pressure, and losing weight. The last competency, which is not as widely understood but is certainly important, is promoting shared decision-?making-getting people involved in their health care so they become active participants in making decisions, respecting their preferences and values. The same care coordinator can do all three of these functions if he or she is supported by technology.

Scott KolesarWhat role does technology play in care management, and what are some of the challenges of using it?

Scott Kolesar: Technology by itself is not sufficient to drive patient care; however it is absolutely necessary to facilitate care management across a large population. In the early days of accountable care, organizations managed relatively small Medicare populations, ?typically fewer than 15,000 patients, where they could manage them with some payer data and a spreadsheet. Those days are gone. Today's care management requires a comprehensive data integration solution, which includes a health information exchange that ingests and normalizes population health data into a robust analytics solution that identifies and prioritizes clinically or financially at-risk patients for care manager intervention.

What's more, the solution must have a dynamic workflow capability that connects care teams and helps them work collaboratively to manage the patient's care, whether that's providing chronic or complex care management; managing care transitions, monitoring self-care, or assisting with end-of-life. ?The system should also curate evidence-based clinical content, which can help to standardize care delivery across the continuum. Unfortunately, such a comprehensive solution is hard to find. There are literally hundreds of vendor products available that have ?many of the capabilities, but no one system does it all. Instead, healthcare organizations may have to consider a multi-vendor, best-of-breed solution to meet all their needs. At Deloitte, we utilize technology and analytics solutions with a combination of vendor solution and best practices to provide that holistic approach.

How can effective care management improve outcomes while reducing costs?

Wennberg: Patient navigation guides the patient to ?the most appropriate, cost-effective care setting. If a healthcare provider is treating a diabetic patient, and he or she developed a care coordination strategy and good relationship with that patient, the patient is more likely to call the physician or provider first before heading to the emergency department (ED). This ?keeps patients out of the acute care setting, because ?you can proactively address issues, assess their symptoms telephonically or direct them to the primary ?care setting as opposed to the ER-all of which reduce costs. Also, self-management-getting patients to engage in their care for chronic conditions, such as diabetes or obesity-is the least expensive, and in ?many ways the most effective care strategy if you're ?in a risk-based contract.

Kolesar: Technology prioritizes those patients who are most likely at risk clinically or financially, such as high care utilizers or those who frequent high-cost sites. An automated solution can put these individuals at the top of a care manager's to-do list and thereby avoid escalating clinical conditions and related high costs. In addition, care management solutions that embed leading practices for a particular condition in provider workflow, permit organizations to deliver care with less variance which has been shown to enhance outcomes and potentially lower costs.

What are the additional investments healthcare organizations will have to make to gain core competencies, and does this mean they should consider outsourcing?

Kolesar: Most care management organizations reside ?in entities outside the health system walls, so there ?can be significant startup costs required to establish ?the enterprise, invest in new technology and human resources. Return on these investments will be a ?number of years away, given that revenue is predicated on successfully delivering good care, changing ?behaviors, achieving improved clinical outcomes and effectively managing the risk-based arrangement. By working with third parties that provide technology and people solution platforms in an outsourced, subscription, or per-member-per-month pricing model, organizations can avoid the significant upfront capital outlay.

As healthcare organizations begin to operationalize care management with the move to value based payment, what are some insights you can share for the future?

Wennberg: Organizations will also need to rethink skillsets and how they will accomplish day-to-day tasks, as some fairly radical changes are going to ?occur in the next 10 years. Everyone from the care coordinator to the organization's CFO will have to shift their thinking. For instance, getting accustomed to tracking patient health using the telephone, text, or email, will be challenging for some. Certain organizations will embrace change while others may accept it gradually. To be successful long-term, organizations must think about the competencies of their senior executives and care management staff as well as their abilities to enable stronger care management.

Kolesar: Technology will continue to play an ever-?increasing role in gathering a wider array of data to both track patient care and alert providers to patient issues. I'm referring to technology such as fitness wearables and remote medical devices that monitor heart rate, glucose levels, weight, and so on. The challenge is what to do with this information and whether or not to encourage patients to use such devices. A lot of this data is not actionable, unless there are sophisticated algorithms and analytics that can take the information and provide insight either in the form of an updated risk score, alert, or direct-to-patient communication. At Deloitte, we leverage analytics platforms to provide solutions for healthcare organizations facing these challenges today. It's very exciting, innovative work.

Are there any additional materials you recommend for providers to improve their value based care strategies?

Kolesar: Visit our website for more information on value-based care insights and thought leadership.


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Publication Date: Tuesday, September 01, 2015