Mary Jane Konstantin, RN

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Most managed care leaders are already well versed in the statistics around treatment adherence. They know that, at any given time, approximately 

 are not taking their medications as prescribed. Other types of compliance, including recommended screenings (e.g., A1c tests for diabetes) can be just as challenging.

The problem of nonadherence is hardly new. It has been recognized for decades as one of the causes of poor health outcomes and high healthcare costs.

But one thing has changed. The industry now has a better understanding of how complex and multidimensional nonadherence can be. Barriers are multifactorial and include treatment-related issues (e.g., side effects), mental health problems, and health system factors (e.g., lack of care coordination). In recent years, the role of 

 has also become clear. These include food, shelter, and transportation insecurity, as well as an inability to access or pay for day-to-day necessities of life.

Trying to help members with these varied and sometimes interrelated issues can seem overwhelming. However, one approach has been shown to consistently help the majority of high-risk members become compliant with care plans and improve their health. It’s a targeted, individualized, and high-touch approach to care management that involves:

Data analytics to pinpoint the right members to reach out to at the right time

Personalized interactions between members and a care management team

When deployed, this approach has provided a ROI of greater than 2:1 for payers, while making significant strides in helping members improve their health.

The following story of Samantha Smith (not her real name) is a good example of how individualized, high-touch care management can assist high-risk members with complex care needs. Numerous barriers got in the way of Samantha’s ability to stay compliant with her diabetes care plan. When a care management team first met her, she was homeless and had unmanaged bipolar disease along with a history of substance use.

Not surprisingly, Samantha used a lot of expensive healthcare services. One year, she visited the emergency department (ED) 22 times. 

Yet Samantha had a good reason to turn her life around: She was pregnant.

To help Samantha, the case manager obtained two grants to cover Samantha’s housing and utility bills. The case manager also referred Samantha to an obstetrician and mental health provider and then accompanied her to the appointments. In addition, the case manager helped Samantha stay on top of the medications she needed to take and connected her with substance abuse resources.

This story shows that members can turn their lives around fairly quickly with the right assistance. Within nine months of entering the case management program, Samantha had delivered a healthy baby boy and was drug-free and housing and food secure. She also had zero inpatient or ED visits during this time frame, except to deliver her baby. 

Samantha deserves a lot of credit for her success. But the care management approach also played a critical role. Specifically, four factors help ensure success in terms of health outcome improvements and cost reductions:  

1. Identify members who are likely to have near-term, high-cost events.

 A common approach for assigning members to care management is to identify high-cost outliers. However, a better ROI can be obtained by pinpointing members who have gaps in care known to significantly raise the odds of hospitalization or other high-cost events in the next 6 to 12 months. For instance, evidence-based research shows that taking mission-critical medications (e.g., metformin for type 2 diabetes) can help stabilize and improve a patient’s health status and reduce unnecessary utilization.

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Predictive analytics can be used to sort claims data to identify members with mission-critical care gaps. Other types of data, including consumer data, can inform these analytical models and help identify members who might be struggling with transportation insecurity and other social determinants of health.

The next challenge is finding these members. There’s often a subpopulation of members who are housing insecure or have other challenges, which makes it difficult to reach them via phone or mail. When traditional outreach fails, it helps to have community health workers (CHWs) on the ground who can physically seek out these members.

CHWs need to be familiar with the local area and know the places members may be found, including gas stations and homeless shelters. They must also be willing to make initial contact with the member in person versus remotely via phone, email, etc. Using this approach, one health plan was able to connect with 75% of members that it had previously deemed unreachable.

2. Identify the reason(s) for noncompliance and assign the right team member(s).

 While it’s fairly simple to identify what members have care gaps from claims data, it can be difficult to determine why the gap occurred. This is where care management teams have an advantage. They can simply ask the member.

The member’s answer should then determine which team member(s) are assigned to the member’s case. For instance, if a member stopped taking a medicine due to side effects, a nurse would be well-positioned to resolve that issue. If it was a transportation issue, a social worker would be the best team member. And if a patient needed help sticking to a healthy diet, a health coach might be assigned. Behavioral health specialists are also available to members with mental health histories.

 An effective care management program needs to continually identify resources that can help members with a variety of barriers to care. This begins with a comprehensive understanding of the member’s benefits and connecting the member to services provided by the health plan (e.g., medication management therapy, transportation assistance). Then care managers need to know about all the resources available at the community, state, and federal level and help members attain needed services. One example is the housing grants that Samantha Smith’s case manager helped her to obtain.

 A trusting relationship is at the heart of care management. It’s not just about connecting patients to needed resources, it also about helping them develop an organized approach for taking their medications, listening to them when they need to talk to someone, and in some cases even accompanying them to appointments.

When case management includes these four components, barriers to treatment get resolved. And they stay resolved: one health plan reported in 95% of cases, the barrier is no longer a problem. Consider Samantha. After she had her baby, Samantha enrolled in vocational training program to become a medical assistant, thanks to another grant the case manager lined up. Years later she is gainfully employed and still treatment compliant.  

Mary Jane Konstantin, RN, is senior vice president and head of business at

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