Not too long ago, it was relatively easy for health plans to identify which members needed a case or disease manager. After all, they were chronically or catastrophically ill, had one or more significant diagnoses and often many thousands – or even hundreds of thousands of dollars - in claims costs.
However, the advent of value-based care has changed the nature of care management. Today’s care managers - who are increasingly called population health clinicians due to their expanded role - are responsible for larger caseloads that include more than chronically-ill members. In addition to working with these members, population health clinicians also are charged with identifying and engaging healthy and rising-risk members and ensuring quality measures are addressed for the entire population. They manage a bigger case load and need to engage more members with various needs.
Enter the Theon® Platform for Population Analytics (Theon® Platform) built on Salesforce Health Cloud.
In late December, Geneia announced its new partnership with Salesforce Health Cloud to better serve the needs of health plans, hospitals, providers and employers transitioning to value-based care. Our joint solution, which combines the Theon® platform’s population analytic capabilities with Salesforce Health Cloud’s workflow, member engagement and communication tools, simplifies and improves the effectiveness of many of the people who work for health plans, including care managers and population health clinicians.
How do health plan care managers use the Theon® Platform built for Health Cloud?
Let’s take a closer look at how Judy*, a health plan care manager, uses the Theon® platform for Health Cloud to improve her member engagement rates, utilization and costs of her patient population, and quality measure performance.
To be successful and engage members based on their individual needs, Judy needs to identify and stratify her patients into categories of:
- Chronically ill and
- Catastrophically ill
Using the Theon® platform built on Health Cloud, Judy easily views the entire population of patients for which she’s providing care management services. She is particularly interested in patients with rising risk. To identify those patients, Judy looks at:
- Future cost,
- Prospective or future risk score,
- Retrospective demographic risk and
- Total cost
Together, these point to a list of members with rising risk.
Charles Green was recently added to Judy’s patient panel. She sees Charles towards the top of her list of rising-risk members. His current costs are just over $24,000, but his future costs are projected to jump to nearly $47,000, and his prospective risk score is more than four.
The Theon® platform built on Health Cloud integrates medical and pharmacy claims information with the clinical record. So when Judy drills into Charles Green’s record, the detail is illuminating. All in one view, Judy sees:
- Utilization in the form of doctor visits,
- Emergency department visits and hospitalizations,
- Open care opportunities, risk trending and risk score,
- Insight into his future costs and his future risk for additional hospitalizations and readmissions
In this case, through the integration of claims information, Judy easily sees Charles had a spike in his medical costs in November.
Within a stratified list of risk drivers, Judy is able to further drill into the risk categories.
Within the medical risk score category, she is able to see exactly which diagnoses are driving Charles’ risk score including his heart failure and type 2 diabetes.
Closing Care Gaps
As a care manager working with providers in value-based arrangements, Judy has to be mindful of the open care opportunities across her patient population and then work to close those gaps for individual patients. In the patient discovery screen, she views Charles’ open care opportunities, including comprehensive diabetes care and controlling high blood pressure. By helping to close them, she may in turn help Charles address his rising risk score.
Given Charles’ level of risk and open care opportunities, Judy can help keep him on track reminding him often and checking in on him to make sure his blood pressure is within range, his weight is in check, and his blood glucose readings are stable.
For Charles, regular surveillance of his biometric data through remote patient monitoring or a health kiosk at his grocery store or pharmacy allows data to be sent back through Health Cloud and into the Theon® platform. Automatically, Charles’ open care gaps are closed, his risk scores updated, and Judy’s task list is updated as well.
As a care manager in a payer organization using the Theon® platform built on Health Cloud, Judy was able to help them improve 19 of the 25 key quality measures that are a part of their value-based contracts as well as improve utilization and cost across the most pertinent areas.
Not only was Judy able to help improve the care for her patients like Charles Green and improve the quality and cost of the population for which she is accountable, but by using the Theon® platform built on Health Cloud, she is able to do so in a manner that makes population health scalable, relieves physicians of the burden, and helps to restore the Joy of Medicine.
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