Care management refers to activities you and your team perform with a goal of facilitating coordinated patient care across the health care system. These activities increase patient satisfaction and improve outcomes while reducing costs to the health care system by avoiding unnecessary hospital and emergency department utilization. Components of care management include:
Care management aims to individualize health care to meet each patient’s specific needs. Health care systems that are patient-centric and outcome-driven are well-equipped to succeed in this work.
Care management and coordination are integral to aligning and meeting the goals of value-based payment (VBP). Practices that utilize the flexibility VBP provides, along with innovative care delivery, will thrive in meeting the quadruple aim of health care—better patient outcomes, lower costs, improved patient experience, and improved clinician experience.
Risk-stratified care management (RSCM) is the process of assigning a health risk status to a patient and using the patient’s risk status to direct and improve care. The goal of RSCM is to help patients achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing escalation to higher-risk categories and higher associated costs.
In this approach, your practice first assigns a health risk status to a patient, and then care team members collaborate with the patient to plan, develop, and implement an individualized care plan. For some, the plan may address a need for more robust care coordination with other health care professionals, intensive care management, or collaboration with community resources.
In a practice panel of 1,000 patients, there will likely be about 200 patients who could benefit from an increased level of support. According to The Commonwealth Fund, this 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1%.
Efforts to implement RSCM have the added benefit of preparing a practice to respond to payment reform. With VBP tied to performance on quality, cost, and utilization, practices must understand which patients they are responsible for managing. RSCM allows the practice to focus valuable time, resources, and effort on patients most likely to benefit from increased support and care management. Learn more about how risk stratification ties to VBP in the FPM supplement “Keys to High-quality, Low-cost Care: Empanelment, Attribution, and Risk Stratification.”
Historical and real-time data, combined with a risk-stratification process and insights from your care team, will help you determine how to be most effective preventing emergency department visits and hospitalizations.
Historical data—aggregated reports from payers, electronic health records and population health analytic tools—can help you determine which patients are at high risk for overutilization of care.
Real-time data, including from regional health information exchanges or direct communication with local and regional hospitals, will help flag when your patient is high risk. Overnight updates using real-time data can prompt your team to schedule immediate follow-up visits that can help patients avoid higher expenditures and prioritize their long-term health.
Watch a short Practice Hack video to learn more about two ways your practice can access timely data and act on it.
These five steps, which can be recalled using the mnemonic I CARE, offer an effective approach to managing care for high-risk patients:
For complete details on the I CARE approach and how to make it work for you, watch a Practice Hack video on this topic. Hear a family physician colleague’s practical review and tips in less than five minutes.
The resources needed to deliver care management vary widely depending on practice characteristics, patient populations, payer mix, and the types of payment models in which the practice participates. Coming up to speed quickly on proper billing practices will help offset those costs.
Family physicians have been managing chronic care for years, but they often didn’t get paid for it. Following AAFP advocacy, Medicare began covering chronic care management in 2015, providing payment for managing patients with two or more chronic conditions that covered activities such as care plan development, medication management, and care coordination.
Under CCM, care provided by anyone on your team (if directed by you or another qualified health care professional) is eligible for payment. CCM is a time-based service with its own documentation and billing requirements, so establish a process to track your time related to CCM; even a simple spreadsheet will do. Accurate billing will ensure that your practice can sustain this important work.
Watch our Practice Hack video on CCM billing to learn which of the required elements you already have in place and can bill for.
You can also use AAFP’s CCM Toolkit to optimize your payment for care management. The toolkit includes easy-to-use customizable templates, resources, and a step-by-step implementation process to integrate CCM into your practice.
The Care Management: Building the Business Case slide deck is a resource that can be used in conjunction with our return on investment calculator to garner buy-in to develop or expand resources dedicated to care management.