EXECUTIVE SUMMARY

Organizations can employ a number of strategies to improve health outcomes and reduce medical spending when engaged in a population health program.

• A first strategy is to select quality measures that are evidence-based and related directly to patient health improvements.

• Case managers focus on quality targets, including screening targets, and chronic disease management goals.

• Changing the organization’s culture from fee-based to value-based care is a crucial part of success in population health efforts.


Case management is an integral part of population health programs that work to improve overall patient health and reduce hospital and ED use by people with chronic conditions and behavioral-mental health issues.

To serve a large population of patients, it’s important to gather health data and quality measures, and to develop goals.

Here is how one data-driven population health and case management program works:

• Select quality measures. It’s important to select quality measures that are evidence-based and related directly to patient health improvements, says Rick Ludwig, MD, chief medical officer of value-based care at Providence St. Joseph Health in Renton, WA.

For example, colon cancer screening can save lives. One quality measure could be that people for whom colon cancer screening is recommended undergo a colonoscopy.

Another quality measure might be to reduce ED usage among high utilizers, including people who visit the ED five or more times a month.

Quality measures could include a target blood glucose or blood pressure level and meeting kidney disease screening goals.

• Case management focuses on quality targets. Quarterly joint operating committees report on risk-based contract outcomes. These are based on claims data, says Barbara Fetty-Solders, RN, MN, CCM, manager of care management at Providence St. Joseph Health.

Some contracts have downside risk and others are upside, meaning the organization receives a bonus for meeting quality targets. “Others are capitated,” she notes.

Downside risk can lead to significant losses, and all risk must be managed well.

“These ACO [accountable care organization] contracts typically have incentives built around how well you do against a cost target for the total population,” Ludwig says. “If you beat a target, you may share in some of the savings, but you don’t get the savings unless you also deliver on quality measures.”

“We learned over time that it takes clinical transformation and cultural change to manage these contracts well,” Fetty-Solders adds. “It takes time to make these changes from fee-for-service to value-based care and quality outcomes, where you’re focusing payment methodology on value.”

Case management is just one of the tools for shifting healthcare to value-based care.

“It’s not just case management, but also focusing on quality targets and defining quality,” Fetty-Solders says. “With these outcomes of risk-based plans, we routinely report on utilization, emergency department use, and inpatient care.”

Case managers contact patients after ED visits and help patients find primary care providers.

• Provide case management help for various patient needs. “I think it’s important to get across to people that the work the case managers do is very creative work and complex work,” Ludwig says. “They’re looking at the whole patient and how they can improve the health of the whole patient. It might have to do with chronic disease, but also behavioral health issues and family issues,” he explains.

For instance, if an elderly patient is falling at home, then case managers can help the patient transition to an assisted living facility, Ludwig says.

“Or maybe the patient’s spouse has a little dementia, and they both live at home but are becoming frail,” he adds.

Case managers also assist with behavioral health issues. “That’s a big issue in a Medicaid population and in the commercially insured population — particularly for those patients who go to the emergency department a lot,” Ludwig says.

“It’s a broad topic, but you do the best you can to engage patients and refer them to appropriate services, whether that’s substance abuse treatment or seeing a psychologist,” he adds.

• Medical assistants can lend help. One model has a nurse case manager and a medical assistant focus on disease management.

Medical assistants check patients’ records to make sure they are up to date on all screenings.

“If the patient hasn’t had a mammogram, then they’re told they are behind on that,” Fetty-Solders says.

Medical assistants help with focusing on quality targets, she adds.

• Use alternatives to helping patients in traditional medical settings. One alternative setting is in pharmacies. Chain pharmacies can provide quick, low-cost medical care to patients with low-acuity conditions.

“Recently, I took my 85-year-old neighbor, who is legally blind, to a Walgreens on a Sunday because he couldn’t hear and thought it was ear wax,” Fetty-Solders says. “It was his ear wax, and he was so pleased to get the ear wax out, and the nurse practitioner showed him which products to buy to keep ear wax out of his ears.”

Another option is to have dietitians take patients to grocery stores to teach them how to read labels and make healthier food choices, says Linda Marzano, senior vice president of value-based care at Providence St. Joseph Health.

• Target high utilizers. “We have good stories about what care managers have done for patients, including engaging patients who would go to the ED every week,” Ludwig says.

Case managers helped to stop patients from using the ED as their primary care provider.

“We have engagement with the entire patient population to help them understand that we’re here for them, and we encourage them to call us before they go to the ED,” he says. “That’s more than care management.”

Nurse care managers focus on the patients with a history of frequent inpatient stays and ED visits, and they try to get these patients’ chronic conditions under control, Fetty-Solders says.

“We encourage the implementation of a care model where they reach out to patients with diabetes and invite them to ongoing case management,” she explains. “The nurse takes their case to a committee or case review, where they go over what medications the patient is on and what the patient’s goals are.”

• Change the culture. The healthcare industry is undergoing a big shift from fee-based to value-based care. It’s a cultural change from being fully focused on production to focusing on the quality outcome, Fetty-Solders says.

Capitated health plans, population health, and a focus on utilization and quality measures are helping organizations make this shift, but it take continual reinforcement, she notes.

“It’s about not jumping to the high-cost imaging tests first, but trying other things that help a patient improve, like physical therapy [or other] non-opioid pain treatment,” Fetty-Solders says.

“Sometimes it takes focusing on advance directives,” she adds. “With an elderly population, make sure advance directives are in place, asking patients what they would want done if they’re hospitalized with a serious illness.”

Every patient should have this conversation about decisions they would like to make, and should discuss these issues with their families.

“I’m passionate about care management and where we can go with this in the United States,” Fetty-Solders says. “Let’s make good decisions around care for our patients.”