Savviest ACOs Leverage Health Plan Resources

Typically, members of a health plan’s care management program are assigned a disease or case manager who connects regularly via phone and, in some cases, visits the home. The care managers become a member’s single point of contact with the health plan. They are charged with engaging and activating members in improving their health and maintaining compliance with their provider’s care plan. Care managers try to anticipate members’ needs and problems, encourage preventive care, and prevent costly unnecessary interventions.

• Disease and case managers at the health plan perform a range of services, all of which ultimately help with the quality and cost of care. They include:
• Facilitating calls between the member, physician, and care manager as needed to clarify treatment plans, medication regimens, or other urgent issues
• Monitoring medication compliance
• Assessing the member’s daily activities and cognitive, behavioral, and social support
• Evaluating the member’s risk for falls and providing education on fall prevention
• Connecting members and their families with professionals who can help with medical, legal, housing, insurance, and financial issues
• Assisting members in obtaining home health and durable medical equipment
• Helping caregivers access support and respite care
• Arranging transportation, meal delivery programs, and advance directive preparation services

Increasingly, the health plan care manager has access to a 360-degree, comprehensive view of each member that includes all of the member’s care, diagnoses, labs, and more—even treatments received outside of the ACO. The most forward-looking health plans are also applying predictive analytics to determine which of their chronically ill and at-risk members are most likely to engage with a care management program. Rather than dedicating their limited patient time to all diabetic patients, for example, providers and care managers can focus their resources on those most likely to follow a diet and exercise plan.

Care managers are most effective when they collaborate with treating physicians. The opportunity for providers, especially those in ACOs or other value-based care models, is to leverage these existing health plan resources on behalf of their patients and integrate them into the patient care team.

Dawn Milstead is vice president of clinical solutions at Geneia. She is responsible for leading utilization and care management operations, health education and wellness, and clinical product innovation. Milstead has more than 30 years of experience in the healthcare industry, including leadership roles in care and service delivery, outcome management and improvement, compliance and accreditation, product development, business process management, marketing, operations, and strategic planning. Prior to joining Geneia, she was the regional vice president for Coventry Health Care’s Mid-Atlantic Region, launched a startup infusion therapy company in Jacksonville, Florida, and practiced pediatric nursing. Milstead earned her bachelor’s degree in nursing from the University of Central Florida and a master’s degree in business administration from Jacksonville University. She is a Certified Six Sigma Black Belt. Milstead may be contacted at dmilstead@geneia.com.