Case Studies
CASE STUDY #1
Overview
A large health system identified numerous internal and external issues with its care management services.
The issues identified were:
Care Managers were not supporting physicians, nursing staff and social workers
Minimum interaction with patients after the clinic visit
Only 70% of Admission Reviews were performed within 24 hours
Care managers underperform on their worklist and have minimal follow-up with physicians and clinical staff
High percentage of missed coordination opportunities
between physicians
Difficulty recruiting CM RNs and with relatively high turnover
High cost due to staff and high turnover limited the ability to
provide CM services for all members.
Care Management Enhancement Approach:
The health system decided to re-engineer its care management services focusing on expanded services, high-performance outcomes, and better patient experience. They incorporated a care management model that included US-based clinical support combined with overseeing the care management support services with nurses based in the Philippines. The outsourced care management company provided real-time web-based EMR interventions and dashboard reports with key metrics across the following functional areas:
- Utilization review
- Care Coordinate
- Discharge planning
- Patient Navigation
- Physician / Provider communication
CASE STUDY #2
Overview
Independent medical group with over 500 physicians
has numerous value-based contracts and over 200,000
covered lives. For one of their commercial contracts
with approximately 12,000 covered lives, there were
been challenges with following up with patients and
meeting the performance requirement of the contract.
During the previous year’s performance contract, they
only achieved a score of 3 of 12 for the group giving up
about $1.6 million in financial incentives.
Results
During a 4 month period, CI was able to touch 93% of
the 12,000 covered lives capturing many of the missing
performance indicators. The Group’s performance score
jumped to 11 of 12 in less than 6 months into the performance
year putting the group on track to receive $1.4 million.
Given the CI innovative care management model and
performance protocols, the CI team’s cost of service was
trackedat a rate of $3.50 per member per month rate:
CI Approach
Care Interventions (CI) was engaged to support the
performance of the 12,000 covered lives through direct
care management support working with the Group’s
on-sight clinical care management team. The CI team
incorporated 3 Philippine clinical personnel to review
the patient’s chart and capture missing performance
indicators provided direct outreach to patients to follow
up on clinical instructions and direct patients to the
office for subsequent follow-up appointments.
