Care management: Optimizing patient-centered care

When you implement care management in your practice, even simple steps can bring about major benefits. The right program can lead to better patient outcomes, lower health care costs, and improved experiences for your patients, yourself and your team. For family physicians who were drawn to the power of individualized care and relationship building, care management is an ideal approach. Patient-centric, outcome-driven practices and health care systems are well equipped to succeed in care management.

Care management refers to activities you and your team perform with the 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.

Care management is in reach for every practice. Beyond the role care management plays in value-based payment (VBP) contracts, it's a model for achieving the bigger goal of delivering value-based care that results in better quality and lower costs of care for patients and practices.

When setting up a care management program, you first need to work with your team to identify the patients who would benefit from extra care. Risk stratification and data review are two methods for making this list.

Combining a risk-stratification process and insights from your care team with historical and real-time data will help you determine how to prevent emergency department visits and hospitalizations most effectively.

How risk stratification improves patient outcomes

Risk-stratified care management 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 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, care teams 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.

Data-driven decision-making in care management

Historical and real-time data, combined with a risk-stratification process and your care team’s insights, will help you determine the most effective way to prevent emergency department visits and hospitalizations.

• Historical data, including aggregated reports from payers, EHRs and population health analytic tools, can help you determine which patients are at high risk for overutilization of care.
• Real-time data, including data from regional health information exchanges or direct communication with local and regional hospitals, will help flag patients who are at 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.

The resources needed to deliver care management vary widely depending on practice characteristics, patient populations, payer mix and types of payment models in which the practice participates. Getting up to speed quickly on proper billing practices will help offset costs.

You're probably already providing elements of care management that you're not getting paid for.

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 (CCM) in 2015, providing payment for management of 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.

Learn how to use CCM codes.

You can also use the 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.

Best practices for family physicians

The mnemonic I CARE offers an effective approach to managing care for patients at high risk.

• Identify: Work with your team to identify the top chronic conditions from your patient panel. This is where historical data and risk-stratification tools are useful.
• Chart Reviews: Identify care gaps and follow-up needs.
• Scheduling Appointments: Be proactive with patients who are due for follow-ups and/or at high risk.
• Manage Referrals: Use your longitudinal relationship with patients at high risk to help them navigate the health care system and connect with needed resources.
• Educate Patients: Provide self-management and care tips, and share information about how and when patients should contact your team.

The AAFP has a collection of tools that can help you start a care management program or boost an existing program.