The population health model in healthcare is gaining ground as the industry recognizes the benefits in quality improvement, reduced costs, and improved health.

  • Case management can have a big effect in population health through a concerted focus on high-risk patients within a population.
  • CMs support patients and help facilitate patients’ learning skills of health self-management.
  • Data collection is an essential component to population health management.

Payer contracts increasingly nudge health systems toward a population health model with the goal of reducing healthcare growth while improving coordination and enhancing the quality of care. When cost drivers are analyzed, health systems invariably find that a small percentage of patients are driving healthcare costs, which suggests that focused case management (CM) can have a big effect on costs, as well as the quality of healthcare.

“There can be unnecessary and duplication of services for the highest cost patients,” says Sreekanth Chaguturu, MD, vice president for population health management at Partners HealthCare in Boston.

“Having case managers work side-by-side with patients to help them navigate our complicated health system when they’re most sick and most fragile is very important,” Chaguturu adds. “This is a strategy to control costs; patients appreciate it because it helps them navigate the healthcare system, and physicians like it because it improves care coordination.”

Accountable care organizations (ACOs) are perfect vehicles for population health and case management because they offer full services to a population, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America in Little Rock, AR.

Other models such as patient-centered medical homes (PCMH) and having case managers embedded in primary care practices also work well with a population health focus, she adds.

“Sometimes people want to define a population in a narrow pathway, disease state, or age limit,” Lattimer says. “When I talk about population health, I talk about the total population you serve: from birth to end of life.”

Among the services this population needs are case management and complex case management with a behavioral health component and partnerships to enhance other necessary services, Lattimer says.

The big question is how to coordinate and integrate that transfer of information, Lattimer says.

“We’ve talked about population health for years, and now we can make it a center of excellence,” she says. “There’s a great opportunity to build a collaborative clinical team with the patient and family caregiver in the center of the team and to help them navigate this continuous care.”

Case managers are there to support patients as they develop self-management skills, Lattimer says. “I really see this as a great opportunity.”

Case management in a population health model can work very well when it’s embedded with primary care provider services, but moving CMs to these offices can be challenging, Chaguturu notes.

“We have to make sure primary care has the bandwidth to take on this new type of work, including time, compensation, and also the space to have case managers sitting side by side in the offices,” he says. “Before you introduce high-risk case management, you should make sure case management is well structured.”

The Centers for Medicare & Medicaid Services (CMS) is beginning to provide financial incentives for case management and care coordination through new codes, including chronic care management codes, Lattimer notes.

“It’s a code that a primary care office can charge for engagement and management of patients with two or more chronic diseases,” she explains. “It includes thorough assessment, interaction, and engagement with the patient.”

While only physicians, advanced practice nurses, and physician extenders can bill with those codes, nurses and case managers can provide the services, and the codes can be used for telephone and electronic health record services as well, Lattimer says. “It’s a great recognition from CMS about the importance of managing chronic care and focusing on population health management.”

Partners HealthCare has different initiatives within the context of population health management (PHM), says Jennifer Wright, RN, CCM, manager for the Integrated Care Management Program (iCMP) at Newton-Wellesley Physician Hospital Organization in Newton, MA.

“The first initiative to get launched under that umbrella was the Integrated Care Management Program,” Wright says. “We also have a behavioral health initiative and patient-centered medical home [PCMH].”

The iCMP is charged with managing the most medically complex and chronically ill patients, who have both high utilization and high cost across the continuum, Wright says.

Partners HealthCare has about 100 care managers to work with nearly 1,000 primary care physicians, Chaguturu says.

“We generally find that a case load of about 200 patients for a care manager is the right balance,” he adds. “We’ve seen some health systems with as low as 50 patients per care manager and others with as high as 400 patients; we’re trying to find the right ratio of care managers to patients.”

The iCMP’s caseload derives from claims-based data, Wright notes.

“We get a list of patients and review their medical records to see if they are appropriate for care coordination,” she says. “Then we validate that list with our primary care providers.”

Also, providers identify patients who need case management services, but are not yet on the claims list. So CMs work with primary care physicians to find patients who would benefit from the service, Wright says.

Case managers and social workers work together as a team. Case managers first meet with physicians, review the records and when it’s agreed that certain patients are appropriate for enrollment, case managers will reach out to patients telephonically or face to face at their doctor’s office, skilled nursing facility, hospital, or home, she explains.

“The way we’ve had the most success is when case managers are viewed as part of the primary care provider’s team,” Wright says.

Patients see the case managers as being part of their primary care provider’s practice and are accepting of their services, she adds.

“We build on the relationship the patient has with their primary care providers,” Wright says. “The primary care provider will say, ‘This will be a great service for you.’”

Then case managers can work with patients to help them navigate through the healthcare process. (See story on how embedded CMs help patients, page 4.)

With a population health model, the key is to use data to determine which patients in a total population are at high risk and to target that subset, Chaguturu says.

Just focusing on managing specific diseases has yielded minimal savings over the years because many patients have more than one disease, he says.

High-risk patients typically have comorbidities and high rates of hospitalization and emergency department (ED) visits. Their comorbidities usually include a mental health issue, says Monica Cooke, MA, RNC, CPHQ, CPHRM, FASHRM, chief executive officer for Quality Plus Solutions in Annapolis, MD.

Case managers should keep mental health issues in mind when looking at population health, Cooke suggests.

“The view in healthcare has to be that one in three or four people you encounter has a significant behavioral health issue that needs to be addressed,” Cooke says. “And we have very few resources in mental health because we’ve basically dismantled the behavioral health system in this country.”

Once patients with mental health problems are identified, someone — often a case manager — has a responsibility to refer them and work with them to get them the appropriate resources they need, Cooke says. (See story on finding resources for mental health issues in this issue.)

“We do see that mental healthcare in the primary care setting is critically important,” Chaguturu says.

“Say you have two patients — one with diabetes and one with diabetes and depression,” he explains. “The one with both diabetes and depression will have 40% higher costs, so treating the patient’s depression will reduce costs.”

Referrals to mental health professionals are challenging because there is greater need for these services than there are professionals able to provide the services, Chaguturu notes.

“We know there will never be enough psychiatrists to treat all the mental health issues that exist in our patient populations, so we need to find ways to integrate them into primary care,” Chaguturu says. “We need to spend time thinking about anxiety and substance use and depression — the three commonly seen issues in mental health settings — and we need to create new protocols and pathways to treat those patients.”