Executive summary 1

Confront your barriers to population health 2

Turning analytics into action: equipping your care manager 3

Care management fundamentals 4

Provide holistic patient-centered care 5

Integrate patient data 6

Create blended, evidence-based care plans 7

Assess patient care gaps 8

Apply evidence-based guidelines 9

Support embedded or enterprise-level provider workflows 10

In summary 11

Endnotes 12

Population Health Management

Reimagining Provider‑based Care Management

McKesson Connected Care & Analytics

The race to manage climbing U.S. health costs and improve

the health of at-risk populations is on.

On average, healthcare costs per capita have grown

2.4 percentage points faster than the gross domestic product

(GDP) since 1970. 1 Healthcare spending as a share of GDP

reached 17.2 percent in 2012, and is expected to rise to nearly

20 percent by 2022.1

With significant revenue reimbursement dollars tied to the

quality and cost of care, providers are investing in the staff and

technology needed to help optimize clinical outcomes and

business results. Since 84 percent of U.S.

healthcare dollars is spent on patients

with chronic conditions2, improving

the health of patients with widespread,

chronic diseases has become a critical

strategy to stem rising costs. Emerging

care management programs offer

a new opportunity for providers to

proactively manage high-risk patient

populations, improve lives and realize

pay-for-performance outcomes.

Executive summary

The cost of chronic conditions

Between 2000 and 2030, the number of Americans with chronic conditions is predicted to increase 37 percent, or 46 million people. More than one in four Americans have multiple chronic conditions, putting them at greater risk for disability and activity limitations. People with multiple chronic conditions experience significantly more physician contacts, use more prescription drugs and are more likely to be inappropriately hospitalized. Physicians believe that patients with chronic conditions have unmet care needs.2

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Confront your barriers to population health

While the initial results of population health programs are promising, success is by no means guaranteed. Healthcare organizations are being challenged in ways that are no less than revolutionary: care is no longer episodic, but holistic, and must focus on outcomes across providers and settings. Providers must improve point of care decisions, quality and cost.

Increasingly, caregivers must look beyond immediate clinical and financial drivers to consider the effect of external societal and environmental forces on patient health.4 Patients struggle to reconcile information from multiple caregivers. Unhealthy, controllable lifestyle behaviors such as poor nutrition, lack of exercise, excessive alcohol use and smoking are significant contributors to the cost and treatment of common diseases.5 To reverse course, patients must assume more responsibility to improve their health, but many patients lack the resources, knowledge and ability to do so.

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Prepared, engaged patients are a fundamental precursor to high-quality care, lower costs and better health.3

Controllable Lifestyle Behaviors

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Translate analytics into action

In light of these challenges and the growth in value-based reimbursement, provider organizations are increasingly leveraging population analytics to identify and prioritize high-risk patients, identify gaps in care, and risk stratify their patient populations. While essential, analytics alone cannot improve patient outcomes; more is needed to translate analytics into action. To bridge the care gap, many providers are also deploying care managers to help coordinate care delivery and apply interventions that improve patient quality of life and outcomes while providing care at a lower overall cost. Sixty-eight percent of respondents to a December 2013 HealthLeaders Intelligence survey plan to restructure their care management program within the next 12–24 months in order to engage in population health and risk management.6

Without supportive analytics and workflow, the job of the care manager can be overwhelming.

• Which patients should be prioritized, and why?

• How can the care manager coordinate interventions for patients with multiple conditions and barriers to care?

• Which patient goals are most critical?

• How can care managers effectively educate patients?

• Perhaps most importantly, how does the care manager know that the interventions are improving patient lives and business results?

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Evidence-basedAssessment

Patient GoalPrioritization

ProgramEnrollment

ComplexConditions

Intervention

PatientEducation

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Care Management Fundamentals

In this new era, provider organizations face a dizzying array of options to address population

health needs. To deliver patient-centered care that provides the clarity and confidence

needed to influence patient behavior and improve patient quality of life, an effective

provider-oriented care management program must fulfill three primary objectives: provide

holistic, patient‑centered care; create blended, evidence‑based care plans that address

multiple patient conditions; and support embedded‑ or enterprise‑level provider workflows.

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1. Provide holistic,patient-centered

care

2. Create blended,evidence-based

care plans

3. Support embedded-or enterprise-level

providerworkflows

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1. Provide holistic patient-centered care Providers need a holistic, insightful view into the patient’s health to deliver high-value care. While patients assigned to disease

registries have comparable diagnoses, their individual care concerns can vary dramatically. Care managers must deliver targeted, personalized care that addresses specific patient issues and connect with each patient in a way that encourages and motivates patients to change unhealthy habits. To successfully intervene with at-risk patients, providers must now consider the whole patient, and incorporate multiple conditions and social determinants to

accurately assess the patient’s care gaps and barriers to access. For some patients, basic living, transportation, support, and financial challenges must be identified, addressed and coordinated with community resources to provide access to the services they need. Care managers must understand all aspects of a patient’s care, reconcile information and make sure the patient has a clear understanding of goals, tasks and actions.

Delivering patient-centered care requires that providers become data-rich and data-informed: combined clinical, financial and quality data creates a holistic patient record needed for performance-based care success. Given the proliferation of diverse information sources such as Electronic Health Records (EHRs), Health Information Exchanges (HIEs), and claims-based data, collecting complete patient information presents an ongoing challenge. Full longitudinal clinical, demographic, registry and care program information are needed. Ideally, risk profile information, such as risk scores, that illuminates opportunities to prevent costly undesirable outcomes, would also be included.

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Integrate patient data

To deliver holistic care, an effective care management platform should seamlessly collect required patient data, such as demographics, vitals and problems, along with valuable complementary data such as pre-adjudicated claims and physicians rosters. Disparate sources, such as practice management, EHR, laboratory, medication history, registry and data warehouse systems, must be integrated. This information must be acquired, aggregated and presented to the care manager in a manner that facilitates quick ease of use. Subsequent data analysis should clinically and financially risk-stratify patients, assign patients to registries, help manage cost

and utilization, and identify key drivers of contract success such as medication adherence and readmission risk. Together, these components can identify which patients would benefit most from care program assignment and intervention.

Care management platforms must also engage patients through multiple forms of communication and outreach, in a way that encourages patient compliance. Education modules should focus on the most common and expensive conditions and use motivational interviewing techniques to increase patient knowledge and participation.

Extracting value from existing data assets is critical to the success of value-based care initiatives. Healthcare organizations continue to be faced with the challenge of gaining value from their data.7

2. Create blended, evidence-based care plansTreating individual disease states for complex cases can quickly become fragmented, redundant and expensive. Coordinated care is

needed to improve outcomes for the most complex and expensive cases. A blended care plan that prioritizes goals for multiple conditions allows the care manager to deliver holistic, patient-centered care. A comprehensive plan should incorporate

impactful goals and interventions in one document while also addressing specific program goals, such as reducing readmissions.

Supporting a unified care plan with efficient workflow and data acquisition can maximize care manager resources. To eliminate redundant data collection, save time and build user confidence and trust, relevant information from existing data sources should be pre-populated

to the patient assessment. Populating the patient-centered view prior to initial contact allows the care manager to develop a clear understanding of the patient’s health status and conduct an effective assessment interview.

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Meet Louise and KarenLouise is a 52 year-old female with chronic uncontrolled Type 2 diabetes, hypertension, and coronary artery disease. Population analytics reveal she’s visited the Emergency Department 10 times in the past year.

Without intervention, her predicted annual treatment cost is $170,000. Her personal goal is to have more energy to play with her grandson.

Louise is assigned to Karen, a clinic-based care manager. At a glance, Karen realizes that Louise is a high-priority patient in her queue. Karen accesses a blended assessment tailored specifically to Louise’s multiple conditions

that is pre-populated with existing lab, medication, and utilization information. Karen contacts Louise to enroll her in the care management program.

Continued on next page

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Assess patient conditions and barriers to care

Once relevant information has been compiled, a care manager can then begin a patient assessment to identify care gaps and barriers. The data-rich assessment should drive appropriate decision points using a single, blended assessment to create an individualized, clinically consistent care plan.

Critically, the patient assessment should uncover and identify opportunities to improve outcomes for chronic, costly diseases as well as transitions of care. To avoid duplication and error, the care manager should not be presented with

redundant questions that are relevant to multiple disease states. The assessment should dynamically update as patient responses and clinical information are provided. The assessment process should culminate in one blended care plan that holistically addresses multiple patient conditions and care goals, and includes standard interventions applicable to the patient’s conditions, such as self-management and symptom recognition. The care plan should also list and prioritize the patient’s personal and medical goals.

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Care assessments that are pre-filled with patient information — medical and prescription claims, conditions, labs, allergies, primary care, specialist and Emergency Department visits, hospitalizations, and risk factors — can build confidence and insight in both care managers and patients.

Assessment and care planGuided by an evidence-based assessment, Karen has the clarity and confidence to ask actionable and impactful condition-specific questions to identify barriers to care and document Louise’s

personal goals. During the assessment, Karen notes that Louise sees multiple providers, is confused about her medication regimen, and lacks adequate knowledge to manage her conditions.

The completed assessment generates an integrated, evidence-based care plan that addresses Louise’s comorbidities, hospitalization risk, and

behavioral, social, and emotional barriers to care. The plan includes priority-based goals, interventions, and education to proactively manage Louise’s care.

Karen creates a single, unified care plan to coordinate Louise’s care across providers and settings. A holistic, patient-centered approach addresses barriers to care to help Louise achieve her medical and personal goals.

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Target Conditions

•Asthma

•CVD

•CKD

•COPD

•CAD

•Depression

•Diabetes

•ESRD

•Heart Failure

•Hypertension

•Low Back Pain 

•Stroke

•TIA

Target Programs

•Chronic Conditions

•Complex Case

•Readmission Reduction

Apply evidence-based guidelines

The patient assessment and care plan should be built on evidence-based content that is informed by medical literature and best-practice recommendations. A sound platform should prescribe interventions based on nationally accepted clinical guidelines such as NCQA QI 7, Complex Care Management, and QI 8, Disease Management.

Guidelines should incorporate condition-specific content and be developed from evidence-based medicine and peer-reviewed clinical studies. Guidelines should be reviewed and updated at appropriate intervals, and address prevalent, high-cost conditions and programs that offer significant quality and cost savings, such as those shown at right.

ResultsLouise receives clear instructions regarding her medications and conditions and demonstrates a thorough understanding of her care plan.

Specific care goals, such as bringing Louise’s labs and blood pressure

within target range, are

identified and prioritized. Louise’s results are stabilized within two months.

Louise begins taking her medications as directed.

Louise receives ongoing counseling for symptom recognition, diet improvement and physical activity. She begins blood pressure self-monitoring and foot care, understands her coronary artery disease and diabetic nutrition recommendations, and recognizes angina symptoms and treatment.

With Karen’s help, Louise no longer visits the Emergency Department to receive care. She avoids two admissions,

saving $32,000 while allowing Louise to remain productive at work and at home.

Louise reports improved energy and quality of life and begins routinely visiting her grandson. She reports a high satisfaction level with the care she receives.

Continued reporting allows Karen to efficiently monitor Louise’s care. Louise’s hospitalization and adverse clinical event risk decreases as her health improves. Ongoing health coaching helps Louise continue to thrive. inLearn more

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3. Support embedded- or enterprise-level provider workflowsCare management solutions must now offer provider-based workflows that can mature and expand to accommodate growth of

both the population being managed and the provider organization. “The burden of care management should not be placed directly on the physician,” notes Andrew Mellin, MD, medical director, McKesson.6 Instead, role-oriented workflows and shared care plans should coordinate care manager and provider efforts.

Provider organizations need an efficient, systematic approach to identify high-risk patients and manage their care. A viable care management platform should allow you to target patients through configurable criteria that align with your care management goals and outcomes.

Workflow is equally critical. Care managers require efficient tools to coordinate care for sizeable patient populations. Patient-centered work queues, dashboards and configurable filters can help care managers prioritize and deliver efficient patient care. Visual cues should lead care managers to take action on high-priority patients and activities.

As population health programs evolve, a care management platform should support both embedded and enterprise care management delivery models. Almost equal numbers of respondents to the HealthLeaders Intelligence survey note that they plan to embed care management technology within a physician’s office (48 percent) or centralize it at a hospital/health system level (46 percent).6 A blended approach may also be appropriate for some organizations. Your care management platform should support your needs regardless of which approach you take.

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Effective, streamlined workflows are needed to identify high-risk patients, assign patients to care managers, conduct clinical assessment, generate evidence-based care plans, manage work queues and items, adjust care plans and document progress.

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In summary

To successfully embrace population health, provider organizations must start early to develop provider, care manager, and organizational confidence in managing patient populations. Now is the time to determine your approach so you can quickly move forward to accommodate value-based reimbursement growth.

Population health success requires new competencies and an automated approach to evidence-based care coordination. Care management platforms that enable a holistic, patient-centered approach, create blended, evidence-based care plans and deliver care within an embedded or enterprise workflow can help position providers for the coming transition. When combined, these foundational elements can provide care managers the clarity and confidence they need to target patients most in need of care, deliver efficient and effective interventions, and partner with patients to improve the health and lives of the patients they serve — while successfully managing business results.

Reimagining care management success

McKesson Care Manager™ provides analytics-informed care management to support value-based care in health systems and networks.

Visit our care management page to learn how McKesson can help you improve population health.

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1 California Healthcare Foundation (2014). Health Care Costs 101: Slow Growth Persists. Retrieved August 15, 2014, from http://www.chcf.org/publications/2014/07/health-care-costs-101

2 Anderson, G. (2010). Chronic Care: Making the case for ongoing care. Retrieved August 19, 2014, from Robert Wood Johnson Foundation: http://www.rwjf.org/en/research-publications/find-rwjf-research/2010/01/chronic-care.html

3 Millenson, M. L. 2014). Expert Voices: Paradigm, Not Pill: The New Role of Patient‑Centered Care. Retrieved August 19, 2014, from NIHCM Foundation: http://www.nihcm.org/component/content/article/867

4 Burghard, C. (2014). U.S. Accountable Care 2013 Top 10 Predictions: Accountable Care IT Strategies, a Period of Maturity Ahead. Retrieved August 19, 2014, from IDC Health Insights: http://www.idc.com/getdoc.jsp?containerId=HI238485

5 American Medical Association (n.d.). Getting the most for our health care dollars. Retrieved August 19, 2014, from http://www.ama-assn.org/ama/pub/advocacy/topics/health-care-costs.page

6 Health Leaders Media (2014). How Care Management Evolves with Population Management. Retrieved August 19, 2014, from http://www.healthleadersmedia.com/forms/Dig_Rep_McKesson_021214/

7 Burghard, C. (2014). Best Practices: Lessons Learned by Early Adopters of Population Health Management. Retrieved August 19, 2014, from IDC Health Insights: http://www.idc.com/getdoc.jsp?containerId=HI249411

Endnotes

Copyright © 2014 McKesson Corporation and/or one of its subsidiaries. All rights reserved. All other product or company names mentioned may be trademarks, service marks or registered trademarks of their respective companies.

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Connected Care & Analytics

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