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Perspectives

Care management transformation

Harnessing an analytics-driven approach

​Discover how patient stratification, a key differentiator of a leading care management model, can be utilized by health systems to coordinate care delivery to provide a better patient experience while reducing length of stay and the overall cost of care.

An innovative and analytics-based care management model is key to reducing costs, increasing patient engagement, and improving outcomes

Changes to the health care industry, driven by the Affordable Care Act, demand improved care coordination, enhanced patient engagement and experience, and cost containment. As a patient transitions across the care continuum, there are disconnects within the current health care delivery system that tend to result in redundant testing, clinical services rendered at a higher level than medically necessary, and loss of financial information—all impacting quality of care, patient experience, and reimbursement.

The ability to connect care delivery with revenue cycle operations is a meaningful goal that can drive both better patient outcomes and improved margins. The right technology infrastructure and workflow processes can provide valuable data that drive analytics to support care transformation. Care and utilization management (CM) programs are uniquely positioned to positively impact care coordination to help reduce cost, increase patient/family engagement, and improve outcomes. More than ever before, an innovative and analytics-driven model for patient care management is imperative.

There are a number of sources, in addition to clinical information systems, that provide data points to better understand resource allocation and consumption, and drive throughout. With millions of data points, understanding what is meaningful and delivers actionable insights is important. One approach is to use patient stratification to understand the patient populations and variances in care to drive operating model changes.

Insights and analytics: Patient stratification

​A patient stratification approach was applied to an East Coast integrated health delivery network. Following merger and acquisition activity, the network needed to integrate and standardize its care management. Patient stratification is a key differentiator of a leading care management model, allowing CM resources and nursing to apply the appropriate level of services based on patient complexity. This can lead to cost and length of stay (LOS) reductions as CM resources are focused on complex cases while working collaboratively with utilization review staff and bedside nursing in managing the care delivery.

For this health delivery network, the directed analysis and modeling demonstrated:
  • Analysis of LOS across all patient encounters identified that the majority of excess stays are just one-two extra days for most admissions.
  • The value of each excess day can be as high as $950–$1,000 for a health system. A reduction of length of stays/excess days by 30 percent across DRGs was made through designing a process for patient stratification and developing a predictive model to set LOS targets based on DRG.
  • Chief medical officer engagement and development of an educational feedback loop to physicians and staff is crucial to gain and maintain buy-in for compliance of timely discharge orders to reduce the excess days identified.
  • 2016 reporting indicated a reduction of 17,000 excess days, or approximately $17M in cost avoidance, due to reduction in LOS.

View all articles in the Sustaining Success series on health care performance improvement topics

Key considerations for implementation

Provider executives ready to implement a successful care management model transformation should consider:

  • Is it possible to hardwire protocol-driven standardized processes that align with clinical and financial objectives?
  • How do we manage key access points for inpatient and observation populations?
  • Can a predictive model for stratification and LOS target setting be built to identify and incorporate this target in the patient’s care plan?
  • How are complex case patients identified and is there a process to ensure the right level of care and a transition plan is assigned?
  • Is there an integrated and collaborative model between care management and revenue cycle to address integration points such as denial prevention and management?
  • Can existing technology be optimized to support redesigned workflow processes and generate performance data?
  • How can data and analytics be assimilated to establish actionable reports and hold key stakeholders accountable?

Related thinking on care management: Creating value with effective care management

About the Sustaining Success series

​The demand to derive greater value from health care is urgent and pervasive. Leading hospitals and health systems are identifying performance improvement strategies which transcend traditional cost reduction and respond to new payment models. Providers that increase value will be the most competitive. Organizations that fail to improve value and protect future margins are likely to encounter growing pressure.

This digest of articles shares examples of how health care providers are pursuing value through both short- and long-term initiatives within the dimension of performance improvement. Providing a view beyond traditional cost cutting methods, the series places a data-driven lens focusing upon how providers can utilize data analytics to identify and implement innovative solutions.

Visit the Sustaining Success series archive to explore the current digest of analytics-based perspectives on performance improvement in health care.

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