Care Management Key Components

Our care management and care coordination services are composed of the following core elements that can be scaled to suit the particular needs of your organization and your patient population.

Relationship Building and Cultural Competency

Built upon a foundation of mutual trust and respect, we believe that achieving positive results in any care management program must start with creating positive client relationships. Creating positive relationships is our number one focus. We understand that without them our clients will likely not engage to the level needed to measure success. To this end our care managers are trained in motivational interviewing, cultural competency, emotional intelligence, effective communication and a unique program called Bridges Out of Poverty.

Behavior Change and Relationships

Care management at its core revolves around behavior change. Whether it’s changing lifestyle habits, medication adherence, or simply attending provider visits, successful engagement necessitates a relationship built upon trust. Our measurable success is built upon our unique ability to create and maintain positive relationships.

Client-Centered Engagement and Activation

Our programs are truly client-centered. It’s not just a catch phrase for us. It’s embedded in everything we do. We understand that for someone to make long-term, positive change patients must be invested and committed to the process. The only way for that to happen is if they are making their own decisions and finding their own motivation. To facilitate a high level of engagement and client-driven activation, we teach our care managers to approach every client as a unique individual and use their extensive knowledge of motivational interviewing and active listening to ensure we are meeting the client where they’re at.

Care Coordination of the Clinical Treatment Plan

The centerpiece of our care management programs are timely, pulsed care coordination services designed to identify logistical and/or systemic barriers that may prevent someone from following through on their clinical treatment plan. In turn, our care managers provide pragmatic solutions to overcoming those barriers.  Our care coordination systems have been proven effective in increasing patient compliance and improving value-based utilization measures. Care coordination consists of:

  • Locating appropriate providers and services
  • Appointment scheduling and reminders
  • Coordinating preventive screenings and diagnostics
  • Referral and authorization processing
  • Identification of logistical, financial, and systemic barriers to care
  • Ensuring clinical information is shared with and received from all treating providers

Socioeconomic Determinants of Health

The fundamentals of our care management programs are built around the understanding that in order to help someone become and stay healthy while encouraging appropriate utilization of clinical services, you must identify and address the socioeconomic determinants of health. We use evidenced-based risk assessments and other screening tools to determine the presence of socioeconomic barriers. If barriers are identified, we then provide high-level case management services to secure necessary resources.

Care Management Workflows

AHN uses the following workflows as the basis for all of our care management and care coordination services.

Initial Client Engagement

We attempt to make the initial contact with a client in-person preferably at a providers office or healthcare facility. We believe this in-person face to face contact enables us to create a successful relationship with them and build a strong foundation for future engagement. Across all of our care management programs the purpose of the initial engagement is to:

·         Introduce the program and services

·         Build a foundation for positive working relationships

·         Complete the needs/risk assessments

·         Creation of the care plan

Supportive Client Engagements

We have pre-prescribed client engagement points that are specifically designed to help support the client in areas such as self-management and health literacy education. The specific time of these supportive engagements depends upon the type of care management program, are generally based around the client’s clinical treatment plan, and are done in person when possible. Across all of our care management programs the purpose of a supportive engagement is to:

·         Create and maintain positive working relationships

·         Provide support with regards to clinical self-care protocols

·         Provide self-management education and support

·         Provide health literacy education and support

·         Re-assess and adjust the care plan as needed

Dynamic Client Engagements

We use dynamic engagements to accomplish the logistical aspects of our care management programs including rendering our clinical care coordination services and our socioeconomic case management services. They are typically performed telephonically, happen as needed to accomplish the goals of the care plan, and encompass all the details required to ensure the client has access to the care and resources they need at the appropriate time in order to be successful.

Care Management Outcomes

Patient Engagement

·         Initial Engagement—We have an average initial engagement rate of 86% across all of our care management and care coordination services

·         Long Term Engagement—We have an average long term engagement rate of 72% across all of our care management and care coordination services

·         Complete the needs/risk assessments

·         Creation of the care plan

Treatment Plan Compliance and Quality Measures

·         Chronic Disease Treatment Plans—Our diabetes care management program has achieved a 98% treatment plan compliance rate with regards to diabetes related primary care, specialty care and diagnostic testing.

·         OB Treatment Plans—Our OB care management program has achieved a 97% compliance rate with regards to the pre-natal care treatment plan, a 98% compliance rate with regards to the post-partum treatment plan, and a 100% compliance rate with regards to the pediatric treatment plan.

·         Post Discharge Primary Care—Our hospital re-admission reduction program has been able to achieve an 83% compliance with regards to a post discharge primary care appointment with 94% of those visits coming within 14 days of discharge

·         Post Discharge Home Health—80% of our clients who are referred to home health accept and receive their first visit within 3 days of discharge

·         Medication Reconciliation—82% of our clients obtain a medication reconciliation within 14 days of discharge, 47% receive a medication reconciliation within 7 days of discharge

Healthcare Utilization Measures

·         ER utilization—The ER utilization rate for our diabetes care management program is 0.5 ER visits per 1000 clients per month, the ER utilization across all of our other programs averages 4.3 ER visits per 1000 clients per month

·         In-Patient Admissions—The in-patient admission rate of our chronic care management program is .09 admissions per 1000 clients per month

·         Hospital Re-Admissions—Our hospital re-admission reduction program has achieved an average re-admission rate reduction of 19.2%

·         NICU Rates—Our OB program has achieved a NICU admission rate reduction of 27%