Six Need-to-Know Guidelines for Successful Care Management

Six Need-to-Know Guidelines for
Successful Care Management

© 2019 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Care managers wear many hats—from patient
advocate to care-team collaborator, care-plan
creator, and patient and family educator.
With this dynamic, diverse job, there is no
such thing as a “typical” day. As each day
changes by the minute, care managers have
to be as agile as the ever-changing human
beings they care for.
Successful Care management

In a complex healthcare system, patients
receive care from multiple providers, all of
whom are considered specialists because
they focus on delivering care in one key area.
The care manager has the ultimate
challenge—putting various aspects of care
together to create a comprehensive vantage
point with the patient at the center.
To add to the intricacy of the job, care
managers have to manage patients, as
well as the unpredictability and constant
change that comes with human nature.

Part of the unpredictability challenge is the
stage of change the patient is in when the
care manager contacts them.
For example, although the patient may
know they have to stop smoking to become
healthier, they may not be ready to commit
to a behavior change to make that happen.
Care managers must assess the stage of
readiness and then guide the patient
through the process until they are ready
to commit to improving their health.

This article discusses six key elements that
empower care managers to advocate for
patients, avoid common pitfalls and roadblocks,
and ultimately ensure the patient receives the
best care—how, when, and where they need it.
1. Patient Advocacy
2. Cultural Competence and Social
Determinant Awareness
3. Leadership Support
4. Communication Skills
5. Data-Informed Patient Prioritization
6. The Human Element

As patients seek care and services from
primary care providers (PCPs), specialists,
social workers, financial aid resources, food
banks, etc., they may feel lost in the
complex healthcare system.
Patients may be unsure about what details
of care are important, when to share them,
and with whom.
1. Patient Advocacy

Often, the most confusing part for the patient
is navigating today’s healthcare system—what
procedures are covered, how to prioritize
personal health goals, and which resources
will help the patient achieve these personal
health goals.
The care manager’s job is to guide patients
through the process and advocate for them
along the way.
1. Patient Advocacy

An example of patient advocacy could mean
working with a patient who is nonverbal but
would like a power chair for mobility.
Ordering and building a power chair involves
many steps and requirements, and patients
and families may not know where to start.
A care manager can help navigate the chair
process, including completing paperwork,
communicating with the power chair
company, coordinating payments from
payer to insurance companies, confirming
what level of functionality the chair must
have, and securing financial assistance.
1. Patient Advocacy

More specifically, power chairs are complex
and can have an array of functions and
accessories, such as being able to tilt back to
relieve pressure or technology that enables
users to operate them within their abilities.
For example, does the patient need a joy
stick or another device to steer the chair?
The care manager must take these things
into consideration so the patient has exactly
what they need.
1. Patient Advocacy

Cultural competence and understanding
social determinants of health (SDoH) are key
pieces of successful care management.
Care managers must master both because
they encounter a variety of people from all
backgrounds.
Cultural competence allows care managers
to positively interact with patients and
understand their healthcare beliefs based
on cultural and religious background.
2. Cultural Competence and Social Determinant Awareness

For example, perhaps one culture does not
view pregnancy as something that would
require attention from a healthcare
professional, leading women to not seek
prenatal care.
Or, a patient may not believe in blood
transfusions for religious reasons.
The Care Manager must understand
the patient’s viewpoint and respect and
advocate for it.

Other SDoH include homelessness,
abuse, lack of access to healthcare,
unhealthy food options, financial
strain, or difficult family dynamics.
The care manager must address all
these in a compassionate way so
the patient feels comfortable
opening up about personal barriers.
A good care manager also under-
stands that these barriers impact the
patient’s ability to change behavior.

One way a care manager can practice
cultural competence is by asking the right
questions to understand a patient’s actual
circumstances, rather than jumping to
conclusions or making assumptions
based on past experience or first
impressions.
A high-caliber care manager will take
the time to get to know the patient and
approach the care plan from a holistic
vantage point.

Support from leadership is critical for care
managers, yet lack of buy-in at senior
levels is a common road block for many
care managers.
Healthcare providers and leadership
haven’t always seen the value of care
management, but that’s changing;
organizations are now seeing that care
management improves patient outcomes
and lowers cost.
If organizations don’t understand this
value, the care manager can create
opportunities to educate and inform them.

Healthcare organizations typically have a
strategy for population health that
includes care management.
However, even if the C-suite is focused
on care management, the care manager
must earn the trust of the individual
providers, many of whom may not have
had personal experience with care
management.

Care managers have to show their value
to leadership through actions, and the
best way to get buy-in from the top is to
show leadership a successful case
example.
This can mean advocating for a chance
to incorporate a complex patient into a
care management program to show
clinical leaders the benefits of care
management.

Another method to garner internal support
is through regular monthly updates to
educate leadership and clinicians about
the value of care management.
Telling providers about success is not
enough; care managers must show
providers the value of their programs.
Fifteen-minute monthly meetings to relay
success stories of improved outcomes
and lowered cost can win over leadership
and create internal care management
champions at the executive level.

Communication skills are crucial to
facilitate a multidisciplinary approach
between all parties—from the patient,
family members, and friends to providers,
social workers, and other caregivers.
An effective care manager nurtures
the relationship with the patient,
leadership team, and providers, all
at the same time, while ensuring
the patient is at the center.

One part of care managers’ complex
duties is to create and present a care plan
that the patient agrees with, and then
effectively communicate that plan to the
family, providers, and other members of
the care team.
The care manager must nurture all of
these relationships so that the entire
team, both clinical and personal, is
involved with the care plan and
ready to play their part for the
good of the patient.

Care managers often face the challenge
of a lack of interoperability due to
outdated EMRs and disparate systems.
Data aggregation and interoperability
would be ideal for a care manager—
because it provides a full picture—but it’s
rarely the case yet.
Many healthcare systems keep data in
multiple EMRs and a variety of non-
integrated sources.
Claims alone does not give the full patient
picture, nor does only clinical information.

The identification of the correct patients
for care management is a daunting task
without predictive risk models and
appropriate stratification tools.
Health Catalyst® Population Builder™:
Stratification Module helps the
organization identify populations and
ultimately helps the care manager
prioritize patient lists and identify patients
who are impactable and appropriate for
care management.

With patient welfare at stake, care
managers must understand the role
data plays in identifying which patients
are the top priority for that day.
A care manager can plan the day, but
interventions may change in an instant
if a patient gets admitted or visits the
emergency department before the
care manager starts the day.

Another example would be the patient who is
discharged to a skilled nursing facility (SNF).
The care manager would need near real-time
data to understand the patient’s functional
baseline when working with the physical,
occupational, and speech therapy teams to
create realistic goals for the patient.
Managing the patient’s functional goals is
important, as a day saved in a SNF can
reduce costs, prevent infection, and improve
outcomes for the patient.

Although the success of a care
management program depends on
reliable data, the most important tool a
care manager has is to remember the
human element of patient care.
Building knowledge of the human
variables that contribute to the patient’s
holistic picture is part of the care
manager’s responsibility.

As care managers get to know the patient
on a personal level—the patient’s likes
and dislikes, family situation, hobbies,
history, etc.—that genuine relationship
will build trust so that the care manager
can guide the patient to care-plan
success and optimal health.

For example, a PCP might refer a patient
to a care management program because
the patient is acting out of character (e.g.,
withdrawn, quiet, and not practicing good
hygiene), but their caregiver hasn’t
offered insight into these changes.
The subtle signs will prompt the care
manager and social worker to carefully
assess the situation, perhaps revealing
important information such as potential
abuse, neglect, or increasing feelings
of depression or isolation.

Attentive, experienced care
management combined with
effective stratification and
comprehensive patient data
separates an average care
management program from a
superior program.

As the nucleus of the caregiving process,
care managers deal with the true
complexities of each individual and must
rally all of the players in a care plan around
helping the patient reach optimum health.
Aside from perfecting the balancing act of
bringing multiple perspectives into harmony
with each other, a care manager becomes
outstanding when the patient’s safety,
health, and well-being drive the decision-
making.
The Difference Between Good and Great Care Managers

It is vital that care managers exercise the six key
elements to success:
 Acting as an advocate for the patient
 Exercising cultural competence and understanding
social determinants of health
 Garnering support from leadership
 Utilizing effective communication skills
 Making data-informed decisions when prioritizing
patient lists
 Recognizing the human element in each patient.
The Difference Between Good and Great Care Managers

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
Six Need-to-Know Guidelines for Successful Care Management
The 3 Must-Have Qualities of a Care Management System
Russ Staheli, MPH
Care Management Analytics: Six Ways Data Drives Program Success
KimSu Marder, RN, CCM, Lead Care Manager
Is Your Care Management Program Working: A Guide to ROI Challenges and Solutions
Amy Flaster, MD, MBA, Vice President, Population Health Management and Care Management
Kathleen Clary, BSN, MSN, DNP , Vice President of Care Management & Patient Engagement
A Guide to Care Management: Five Competencies Every Health System Must Have
Russ Staheli, MPH
Identifying Vulnerable Patients and Why They Matter
KimSu Marder, RN, CCM, Lead Care Manager

Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
KimSu Marder joined Health Catalyst in September 2015 as Care Manager Lead. Prior to
coming to Health Catalyst, she worked for Tufts Health Plan as Care Management
Relationship Manager. KimSu has a degree in Education from Lesley University, a degree in
Nursing from Regis College, and is currently working on a Psychiatric Nurse Practitioner
MSN at Regis College.
KimSu Marder

Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement company
that helps healthcare organizations of all sizes improve clinical, financial, and operational outcomes
needed to improve population health and accountable care. Our proven enterprise data warehouse
(EDW) and analytics platform helps improve quality, add efficiency and lower costs in support of more
than 65 million patients for organizations ranging from the largest US health system to forward-thinking
physician practices.
Health Catalyst was recently named as the leader in the enterprise healthcare BI market in
improvement by KLAS, and has received numerous best-place-to work awards including Modern
Healthcare in 2013, 2014, and 2015, as well as other recognitions such as “Best Place to work for
Millenials, and a “Best Perks for Women.”

Six Need-to-Know Guidelines for Successful Care Management

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Six Need-to-Know Guidelines for Successful Care Management