5 Ways to Address Care Management Models That Don’t “Move the Needle”

Traditional models of ambulatory care management will need to overcome 5-key hurdles to support new risk models like Primary Care First in a meaningful way.

Here are 5 challenges and ways to address them:

1) Ambulatory Care Management Models Need to Become Economically Feasible. Most Models are Too Expensive at the PMPM Level to Appropriately Scale.

Traditional ambulatory care management programs struggle to justify their existence in terms of impact and ROI when orienting towards new risk models.

Making an impact is possible. However, many programs don’t survive in the long term if they fail to impact measurably.

For health systems the challenge is that they require effective programs at scale that also match their environment and “corporate” reality.

This of course creates two questions:

  1. What is the right scale so that an impact can be made at the health system level?
  2. How do you make that sort of large-scale coverage economically viable?

To answer the first question, let’s look at an example from a recent project and associated analysis.

The inflection point for this customer, where the opportunity of impact diminishes quickly and beyond economic return, is located between the top 10% and top 20% of a typical population serviced in primary care. Based on our studies, we know that the top 10% most complex patients drive approximately 90%+ of the total cost of care.

Assuming a 50% program participation rate (this takes a consumer marketing approach to achieve, more in a later post), this means the program is involved in the management of over 45% of the total cost of the population.

This type of scale creates meaningful impact of a care management model and can support the financial needs of the organization while improving community health. A “skinny” program, on the other hand, has little measurable impact and little chance of long-term survival and thus becomes a self-fulfilling prophecy.

Moving on to the second question: How do you deliver care management at this scale while making the financial aspect work?

It can be done, and here is how:

  1. Use a leveraged model, highly leveraged, by introducing health coaches into the process. With the right model, process and technology, 1 licensed staff can support between 3 to 7 non-licensed support staff
  2. Use remote staff to gain access to qualified health coaches at reasonable rates
  3. Create the environment such that health coaches can support 100 to 175 patients each

Beyond these “scalability points” the program must be designed well beyond clinical and SDoH management. Create a program that has high rolled throughput yield throughout all process elements, from identification to escalation avoidance.

These steps are examples of how to rethink care management to create scale that delivers measurable results at the population level.


2) Ambulatory Care Management Models Need to Reach More Patients. Because They are Expensive, Many Don’t Have Enough of a Footprint in the Managed Population to Deliver Measurable Results.

Anyone involved in population health work understands not only the significance and importance of this work, but also the difficult odds in “moving the needle” (making a quantifiable difference) to justify the program.

Let’s take an example of a panel of 10,000 patients in a primary care practice.

You need to demonstrate measurable and meaningful improvements in healthcare consumption and cost. However, if you have 2 care managers working a typical caseload, you are probably “touching” less than 1.5% of the panel in a meaningful way.

Some of the 1.5% are probably not the most critical, others are not at all that compliant, and you quickly see that Vegas odds look good compared to this.

That is why creating a model that augments licensed staff with non-licensed staff is so important. You just need better odds.

Moving the needle on 1.5% sounds more like hopes and dreams; to move the needle you need coverage more in the 5-10% range.


3) Patient Activation and Engagement Must be Much Higher and Behavioral Economics are the Gateway.

Behavioral economics are foundational to successful practice-based care management. It is the key to “compliance” and care plan activation. What this means is that you must structure the entire care plan design and execution process with behavioral economics in mind.

It means that creating big, meaningful and realistic “rewards” in the form of joyful and positive life objectives must come first. Next, worry about the care plan content.

It means “taking my medications as prescribed” is NOT a patient goal that will activate and engage (best case it is a care plan item, and not a good one at that, as it is not personalized)

It means spending some time with patients helping them envision the positive future state, so it becomes real in their mind, which moves it from an uncertain future gain to a certain loss if they don’t engage (powerful visioning will do this!) and “flips” the 2:1 ratio to support care plan execution.

There is much to consider here, but much of this type of work received the Nobel Prize in 2002.

In a recent project re-engineering care management, this topic created a lot of meaningful debate. It resulted in a process that can be taught and scaled to help care management teams leverage the concept of behavioral economics in care plan design, and thus help overcome the challenges of “care plan compliance”.


4) Care Plans Need to be Personal and Personalized to Achieve Activation.

Relying solely on skills of care management staff is insufficient in identifying the best practice care plan items, it requires evidence-based tools. Much work has been done at the disease level on this subject. For an effective care management program, supporting complex patients now needs to be assimilated and normalized to fit into the context of comprehensive care plans across many conditions with the same individual.

However, even this is only half the story.

Above, I talked about the impact of bringing the concept of behavioral economics into goal setting for care plan design. One of the other key steps is the true customization and personalization of care plan items.

We are not just talking about dosage of medications here, but the behavioral components of Comprehensive Shared Care Plans. Personalization in that context means not using canned suggestions like “moderate exercise 3x per week” for patient care plans, but something meaningful to the individual, like “walk to the post office and back 3x per week”.

The more we personalize care plan items, the better we link them to the goals determined using behavioral economics principles, the higher the likelihood of item completion.


5) Barriers Need to be Actively Removed. This is the Dance of Providing the Exact Amount of Help Needed. Too Much and We Enable, Too Little and Activation and Results Will Suffer.

The objective of a well-done program is to mentor and support for higher levels of self-sufficiency and advocacy. This is a tough challenge to operationalize (deliver reliably, with high quality across scale).

It is difficult, as human beings, to know where to draw the line between support and enablement.

In our most recent care management program, I ended up entering a lengthy debate about how much support to give a patient. On one hand, you want to support and make sure the person has the resources they need available to them, be it getting a needed appointment or food. On the other hand, you do not want to be enabling.

Patient activation becomes a key measure to successfully navigate this challenge.

One example of a patient activation measurement is from a recent project: For each patient we created a standard score for measuring patient activation across several dimensions. We designed it to be completed in 60-90 seconds, each time we interact with the patient.

The score ranged from 1-5, 1 being a poorly-activated patient and 5 being a highly-activated patient. The measurable objective for the team became building the patient from the current score to a maximum score of 5 whenever possible.

Say the patient is at a level 3, the team provides the support to get to a 5 over time (assuming the patient is capable), so a “plus 2” delivered by the team.

Clear measurable definitions for patient activation supports the health coach with the dilemma of what constitutes support and when they are enabling. The support provided is what needs to be done at that moment, in parallel to coaching the patient over time to higher levels of patient activation.


Successful Practice-Based Care Management Requires Fundamental Rethinking of the Traditional Definition of Care Management.

These 5-elements provide the keys to deliver successful programs such as Primary Care First that reliably “move the needle” for patients and organizations alike.

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