Care Management

About Care Management

Preventive PLUS care management programs apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.

Care Management

The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.

Care Management Framework

The following framework (see below) outlines and defines the key components of a comprehensive care management program and provides examples of tools and strategies that can be used by states in designing programs to effectively meet the needs of beneficiaries with complex and special needs.

* Care management framework adopted from Center for Health Care Strategies, Inc.

Care Management Components Definition Tools / Strategies
Identification Stratification Prioritization Identification, stratification, and prioritization should be used to identify consumers at the highest risk who offer the greatest potential for improvements in health outcomes. Programs should incorporate clinical and non-clinical sources of information to identify consumers who will most benefit from care management.
  • Health risk assessments
  • Predictive models (algorithm–driven model that uses multiple inputs to predict high-risk opportunities for care management)
  • Surveys (e.g., Patient Health Questionnaire 9, Short Form 12)
  • Case finding (e.g., chart reviews, surveys)
  • Referrals (from member, provider, community)
Intervention Interventions should be tailored to meet individual consumer need, respecting the role of the consumer to be a decision maker in the care planning process. Interventions should be designed to best serve the consumer, be multi-faceted, improve quality and cost effectiveness, and ensure coordination of care.
  • Evidence-based practices
  • Interactive care plan, developed based on consumer-set priorities
  • Multidisciplinary care teams
  • “Go to” person
  • Medical home
  • Physical/behavioral health integration
  • Specialized patient engagement (e.g., self-management training)
Evaluation Evaluation should include systematic measurement, testing, and analysis to ensure that tailored interventions improve quality, efficiency, and effectiveness. Careful and consistent evaluation will build the evidence base in terms of what works for complex and special need populations.
  • Program evaluations
  • Rapid-cycle micro experiments (e.g., continuous quality improvement, testing, and program adjustments)
  • Representative measures of quality (e.g., HEDIS, CAHPS)
  • Representative measures of cost (e.g., ROI calculations)
Payment/Financing Payment/financing should be aligned to support improvements in care management by rewarding consumers and providers for participating in interventions/evaluations and establishing accountability for quality and cost.
  • Pay for performance at multiple levels (e.g., health plan, provider, and consumer level)
  • Share in program savings (gainsharing)
  • Case management/medical home payments

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