Care management for high-risk patients

To manage high-risk members, a community-based, team-based approach provides the best balance of quality and patient care. Care management teams should include a physician, a care manager, a pharmacist, a behavioral specialist and a social worker. Payers typically have the most experience with care management, but a 2012 study[1] confirmed that providers who are part of an ACO are preparing for care management as well.

A care management team should include not only members of the medical group but also individuals from the health plan, community resources and vendor partners. While the physician provides the care, the care manager can support theCynthia Kilroy patient as an extension of the practice. The care manager leads a collaborative process of assessing, planning, facilitating and advocating to meet the patient’s individual needs. The care manager’s interventions help patients see the right care provider as indicated by the physician, take the right medications, receive the right and most clinically appropriate care and live a lifestyle that will afford them improved health.

For those members that are not at high risk, a “health advocate” or “health coach” approach can ensure the proactive support of consumers’ health care needs. The advocate is a source for a member’s health-related questions and needs, helping the member navigate the health care system and promoting access to care and overall well-being. The goal is to create trusting and lasting relationships that support long-term behavioral change by focusing on the member’s individual needs.

Be sure to catch the final post in this blog series, which will focus on applying technology to support information exchange and decision making.

ACO Partners Better Prepared for Additional Care Mgmt Responsibilities

[1] Multistakeholder Survey, Optum Institute-Harris Interactive. Optum Institute for Sustainable Health, July 2012.

This post is the tenth of an 11-part series that proposes structures and actions that characterize successful accountable care organizations. Click here to download A Model for Value-Based Provider/Payer Partnerships white paper that covers the subject more in-depth.


More from this series:

Cynthia Kilroy, Sr. Vice President, Provider Strategic Initiatives, Optum

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  1. Pingback: Leveraging technology to support the sharing of information and drive decision making | Healthcare Exchange

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