As emerging trends towards value-based payment and population health management continue to dominate the healthcare landscape for government and private payors, population health management strategies like case management (CM) and disease management (DM), also continue to serve as key approaches towards these outcomes.
Historically, these management programs provided health plans the framework to manage overall cost and quality of their member populations, working with both members and their provider networks. Case management additionally has been used in federal, state, and local governments for managing both healthcare services for fee-for-service populations through their respective agencies as well as an integral component of economic development and self-sufficiency programs.
What’s different today?
- The increased evolution of these programs become part of provider-based strategies, whether from an ACO (Accountable Care Organization) perspective or those providers in shared risk arrangements with CMS or managed care organizations
- The expanding trend for economic redevelopment in distressed communities to incorporate a greater focus on the value of community case management for both individuals and families for improved outcomes across social determinants of health.
What roles do CM and DM to support public health initiatives?
Case Management: While there are several key differentiators in terms of how these programs may exist within either government, provider, or private payor organizations, they fundamentally are aimed at two major drivers: the appropriate utilization of healthcare services and the management and/or control of the disease.
Case management is focused on individual outcomes, are managed or overseen by case managers who may be clinical or non-clinical depending on the program, incorporate the development of an individualized case plan focused on specific needs and goals and whose engagement can range from a couple months to several months. Case management also specifically focuses on helping the individual navigate defined issues and barriers towards either independence and self-sufficiency or reduced utilization, and can include supports such as education, transportation, community services, and coordination.
Disease management: DM focuses on chronic diseases, the early identification for members in all stages of disease (primary to tertiary prevention) and aimed at both improving quality of life and progression of the disease. Disease management is typically derived from a clinical algorithm based on evidence of chronic illness like Diabetes or Asthma for example, through coding, claims, or direct member input and the identification of inappropriate utilization of services such as increased emergency admission rate or hospitalizations or non-compliance with medication refills or regular primary care physician (PCP) visits. Typically, these algorithms further triage the universe of members in these cohorts to some type of tiering to guide the level of targeted interventions. This can be anything from sending out preventive reminders to the entire cohort to specific interventions like mailers, postcards, robo-calls, or telehealth services for specific cohorts.
While these programs reflect just some of the approaches used to improve person-centered engagement for optimal health and well-being, implementing programs like CM and DM enable government agencies accountable for human and social services, the opportunity to structure resources and goals within a construct that supports self-sufficiency and cost savings.
ARDX®‘s long-standing history of bringing customized solutions to federal and local governments allows us to simplify the changes occurring across the healthcare and public health landscape to deliver impactful strategies that deliver quality outcomes by improving health and lowering the cost of services. This includes our experience providing healthcare consulting and technology solutions to federal, state, and local governments and our focus on public health to improve outcomes for wellness and self-sufficiency.