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Care coordination programs adapt to real-world challenges


Once limited to major disease states such as asthma, diabetes andcongestive heart failure, disease management has become a far morecomprehensive tool for health plans. Not only has it expanded toencompass less-prevalent conditions such as Hepatitis C and Lymedisease, it addresses non-clinical barriers to care, such asscheduling and patient transportation.

Once limited to major disease states such as asthma, diabetes and congestive heart failure, disease management has become a far more comprehensive tool for health plans. Not only has it expanded to encompass less-prevalent conditions such as Hepatitis C and Lyme disease, it addresses non-clinical barriers to care, such as scheduling and patient transportation.

It does no good to manage the chronically ill in doctors' offices and medical facilities if the member has no means to get to the appointment. After the industry has struggled for years to increase member participation in DM programs, companies such as Philadelphia-based AmeriHealth Mercy have gone one step further to address the socioeconomic barriers that many members face-particularly those in the Medicare and Medicaid segments, and members in rural settings.

It's important to realize that care coordination (also known as intensive care management, or ICM) isn't simply a dressed-up disease management program, according to Tom Lyman, senior vice president of market expansion at AmeriHealth Mercy. "PerforMED, our care coordination program is a population-based health management program that uses many of the same tools as traditional DM programs, such as predictive modeling," he says. "What makes it different is that it doesn't address individuals with disease states, per se...it addresses the 10% of a plan's membership that spends the most money, regardless of chronic illness. PerforMED is a best-practice case management program that provides one-stop, blended programs to our members."

"Without folding in new technologies and borrowing longer-term engagement strategies from pure DM programs, today's care coordination programs look no different than case management from yesteryear," according to Joel Hoffman, a principal in the Denver office of Reden & Anders Ltd. "Predictive modeling, enhanced engagement stratification engines, and staying in touch with the patient after the culmination of a high-cost event afford better outcomes-and thus better returns over traditional case management. It's like case management on steroids."

Tracking individuals through a fragmented and compartmentalized healthcare delivery system is a daunting task, says JoAnn Balara, RN, BSN, manager of care management products for Phoenix-based QCSI, an IT solutions provider for healthcare payers. "In order to truly improve the outcomes of these special needs populations, health plans need systems that provide visibility into a member's care across the entire healthcare continuum."

Compared with traditional DM programs, it's easier for health plan executives to understand the value of care coordination initiatives, Hoffman points out. "There's an intuitive understanding of the value that these programs have," he says. "Despite a very long and prosperous run for disease management, it could be said that the industry still struggles at times to demonstrate a true cause-and-effect relationship of disease management programs with outcomes. But care coordination is more hands-on with the people that cost the most, and therefore its impact may be more easily understood by customers. To this end, many traditional DM companies have added care coordination or Intensive Case Management capabilities."

Lyman concurs, adding that "the key to successful care coordination is getting the information necessary to manage the care of members into the hands of those who are charged with managing that care."

Treating this population with a non-coordinated approach doesn't address the driving factors that underlie the problem, and sooner or later, you'll run out of options.


When AmeriHealth Mercy realized that its previous efforts at disease management weren't lowering costs and improving outcomes, the plan decided to conduct a population profile of its members. The comprehensive study showed that the majority of its highest spenders (more than 80%) were in the Supplemental Security Income (SSI), aged, blind or disabled category.

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