Effects of Community-Embedded Care Management Model on Patients, Providers, and Payers

November 2018 Vol 9, NO 11
Sheryl Riley, RN, OCN, CMCN
Saisystems Health

Background: Comprehensive oncology care management builds on expert clinical support and coordinated services but lacks a community focus during critical phases of the cancer journey. A community-embedded approach can fill this crucial gap by extending oncology programs past practice walls, incorporating local resources, and identifying barriers to care between office visits.

Objectives: The cycle of care management adheres to the following objectives:

  • Improve health outcomes
  • Engage the patient, their family, and healthcare team
  • Advance payer efficiency and cost savings
  • Support the treatment plan in the community

Methods: Saisystems Health deploys a risk-based process implemented through proprietary stratification software, intriCare. The solution compiles all data points of the healthcare system for analysis, including pharma, HRA, claims, disability, and more. Based on these factors, our team calculates a 3-step risk acuity score for each patient to assure treatment plans meet their individual needs. Patients are then designated to care programs in accordance with their risk levels. This allows for personalized care plans and staff workflows that produce optimal health outcomes. Care teams of a care coordinator, registered nurse, and social worker provide consistent healthcare navigation, monitor patients’ treatment adherence, and work to improve health outcomes. They act as a safety net for patients and their families at all times. The continuous flow of communication allows team members to cohesively evaluate various aspects of care and communicate with patients’ other primary health providers.

Results:

  • 9.6% decrease in emergency department visits
  • 24.7% decrease in hospital admissions
  • 22% improvement in medication adherence
  • 20% increase in member compliance
  • 8.4% cost savings from smarter spending
  • 12.5% rate of scheduled MD visits versus unscheduled
  • Hospice conversion at 8 times the national average
  • Improved side effects management
  • Return on investment of 3:1

Conclusion: Through community-embedded oncology care management, patients not only receive the proper level of care but also show various improved health outcomes. Providers and patients experience decreased emergency department visits, shorter hospital stays, and improved quality of life, whereas payers realize tremendous cost savings due to smarter spending and utilization management strategies. Practices continue to recognize community-embedded care management as a transformative standard of treatment that is central to positive health outcomes. However, as the health community pushes to implement this type of treatment in more practices, we recognize an ethical duty to learn as much as possible and improve on our methods. As part of quality assurance initiatives, Saisystems Health conducts constant evaluations of quality metrics to ensure our teams are providing the very best to patients, providers, and payers.

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November 2018 Vol 9, NO 11
Last modified: November 9, 2018

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