Train your care managers to act like detectives
Tina Spector, vice president of clinical integration and innovation at Medical Home Network, likes to tell the story of how one patient was in disbelief when his care manager showed up to see him when he was in the hospital.
“He had no idea how she found him there,” Spector says. “By looking at the data, our care manager was alerted that he was at the hospital and she went to check up on him.”
Stories like these require care managers to do a little detective work. By looking at data and digging into technology tools, they’re able to piece together a whole picture of a patient.
Interoperability is one of the greatest challenges the healthcare industry faces, causing care managers to act like detectives. Patient information lives across various systems that are used to manage a patient’s health. These include: EMR’s, Care Management Systems, claims data, scheduling systems, state databases for immunizations and prescription monitoring.
Currently, CMS is motivating the industry by revamping “Meaningful Use” and renaming it, “Promoting Interoperability.” CMS will be driving new initiatives to create interoperability across the healthcare ecosystem.
“It can be difficult to figure out how to incorporate data from various points across the system, but care managers have to allow information to empower their workflow, not give them more work,” says Laura Merrick, senior product manager at Medical Home Network.
Here are a few ways to foster an environment of sleuthing—and get a grip on interoperability:
Start a boot camp or an academy program for care managers
On average, it takes about six months of training for someone to become a police officer and another five years of training before they become a detective. A commitment to workforce development is important for caregivers, as well. At MHN, for example, care managers go through an extensive care coordination certification program. This involves taking 10 classroom courses around diseases, patient behavior, motivational interviewing and the basics of care management. New care managers are also sent to Rush University College of Nursing for hands-on experience in a simulation lab.
Encourage care managers to share ‘leads’ with each other
Both detectives and care managers know that solving a case takes teamwork. Instead of the care manager feeling like they have to figure everything out by themselves, it’s important to create an environment where new care managers can talk with veterans about best practices and advice. If everybody has an idea on how to get in touch with an “unreachable patient,” perhaps one of those ideas will work.
Don’t give up on ‘unreachable’ patients
Detectives chase down cold calls, hot tips and legitimate leads. The same should be true for care managers. “Unreachable” patients are the ones who don’t have a good phone number, email address and are difficult to track down. However, “unreachable” patients might follow similar patterns in the system. Maybe they go to the ER every Monday at midnight? Encourage care managers to start building relationships with hospital staffers. Once a connection is made, odds are that information about the patient can be exchanged quickly, increasing the care manager’s opportunity to engage with the “unreachable” patient. Get ahead of the data and anticipate what can happen next.
Practice motivational interviewing
Detectives know how to gain a person’s trust before they start asking the hard questions. That’s the sweet spot care managers want to focus on when they do their motivational interviewing. Getting an honest health assessment from a patient depends on how strong of a relationship a care manager is able to develop with the patient. Set aside time each month for care managers to practice doing mock interviews with each other. Knowing how to ask questions in a thoughtful, empathetic way will help care managers understand the core of what’s really happening with the patient.
How providers can improve chronic disease management
The right people, technology and community resources are key to lowering costs and improving outcomes for people with chronic conditions. With these in play, the focus can shift from reactive, crisis-based care to prevention of deterioration.
HEDIS takes a village. Payers, providers, and the patient all play a role, and it can’t be done without data to prioritize and maximize efforts. Those who embrace this will increase the likelihood of improved outcomes.