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.
3. Line up resources to help. 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.
4. Show up for the member. 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.
A long-term solution
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 AxisPoint Health.