Optimizing Care Management for Success in Risk Bearing APMs 

An Overarching Theme in APM Success is Care Management.

While primary care has been straddling between Fee for Service (FFS) and Value-Based Contracting, there appears to be a tipping point approaching. After years of Comprehensive Primary Care (CPC) and subsequently Comprehensive Primary Care Plus (CPC+), Alternative Payment Models (APMs) are increasing across payers. Launching in January this year and anticipating a Cohort 2 group of primary care practices starting January 2022, CMS’ Primary Care First (PCF) is another practice-level contracting option for practices in 26 regions across the United States. 

While many roadmaps and change packages have emerged, an overarching theme especially relevant in APM success is care management. The role of Care Manager is widespread, yet significant variation remains. Perhaps a good thing if based on the needs of a given population. However, it bears examining if the variation is not based on alignment with unique population and patient needs, and is rather based on a wide range of functions and tactics under the umbrella of care management or care coordination.   

As numerous as the functions (and titles) of care management, so too, are the variety of places Care Managers may be employed. Patients are contacted by Care Managers from primary care, other specialists, payers, and hospitals. This alone may increase the need for coordination to manage confusion experienced by patients and families.   

So where to start…? 

Whether you’re starting a new Care Manager team, or you have a long-standing approach to care management, there is opportunity to optimize, increasing the likelihood of success in value-based payment options, particularly those with upside and downside risk.  

Don’t start with a job description! 

…and if you did, it’s not too late. This subtitle represents a common misstep in building risk-stratified care management teams. Lead with the outcomes you desire. You are considering an important investment…  

What’s your objective? What do you hope will happen as a result of hiring a Care Manager(s)? Make sure you and your leadership are in sync on this. One way to solidify consensus is building a care management scorecard. Consider a Triple Aim approach to the scorecard. Do you expect to see improvement in all areas, or will impact be targeted (e.g. reducing ambulatory-sensitive admissions such as Acute Hospital Untilization (AHU) performance in PCF)? Should the focus be on episodic or longitudinal care management (or both)? For what percent of your high- and rising-risk patients will you provide additional care management support? 

What do you know about your empaneled population? If you haven’t risk-stratified your empaneled population – start there! Risk stratification is a resource allocation tool. Not only does it identify patients requiring additional support, it provides insights to the needs of your population, and informs who is on the care team at each level of risk. As you think about your patients overall, look for trends… Is there a prevalence of specific chronic conditions? Is there a high incidence of polypharmacy? Are there behavioral health or social needs? Are ED and admissions/readmissions above benchmark? Is patient activation a significant challenge?   

What is the return on investment (ROI) and value on investment (VOI)? For ROI, what performance measures are impacting your payment? Where are you leaving money on the table? Are there revenue sources that should be considered in designing the Care Manager role (e.g. if FFS… Remote Patient Monitoring, Transitional Care Management, or Chronic Care Management codes)? Consider sustainable funding options in your approach to care management. Equally important to consider VOI and the future value of investments made now. Other considerations directly impacting VOI (and indirectly ROI) include the positive impact care management can have on patient experience, continuity (antithesis of leakage) and provider satisfaction.   

All these inputs are critical before thinking about titles and job description tasks. They will inform what experience to hire (e.g. RN, SW, pharmacy, behavioral health professionals), and they ensure you can validate your investment based on agreed upon measures of success.   

Finding the Right Someone… 

Once you have a clear picture of desired future state, you are informed in pursuit of great candidates. There are, of course, the more tangible requirements and credentials informed by the above considerations and the consensus on expectations you now have of the role. Ah, but those intangibles… Because this person will be working with patients at high- and/or rising-risk, dealing with difficult challenges, and a key member of your team, consider the following qualitative characteristics in your search…  

Do they have a teaming mindset? It will be critical that the Care Manager can foster strong relationships as part of an integrated care team. It may be effective to consider interdisciplinary care conferences for a cross-functional approach when progress is stalled. Additionally, there will be a need to reach beyond the walls of the practice to problem solve and coordinate. 

Are they assertive and others focused? Often times the person in this role will need to think outside the box to understand what is causing barriers to improvement for patients, and reach out to navigate (e.g. working with inpatient case managers, connecting to needed community-based resources, addressing breakdown in processes and communication). 

Do they like data and are they driven to improve? Not everyone likes data and technology. While the human factor is essential, it’s important to find someone who is curious and eager to see the results of their work. Look for resilience to bounce forward when faced with extenuating circumstances.  

Do they have the ability to coach, not only educate? There is a difference. Particularly as clinicians, we feel responsible to provide educational resources and instruction. While providers and care teams must advise, there must be space to elicit input and buy-in from patients. Often this coaching interaction is codified in a bi-directional collaborative care plan (different from a plan of care or after visit summary). 

Are they likely to be a trusted resource for patients? Establishing a trusted relationship based on equity and honoring lived experience is essential to engage patients and families.  

Data, data, data! 

Don’t let this subtitle fool you, more data does not always tell you more. However, actionable, reliable, timely, role-based data is critical. Care Managers are flying blind without data that allows them to zoom out (look across population segments) and zoom in (drilling down to patient level data behind the trends). Acknowledging all the usual challenges of data from disparate sources, functionality of data analytic and HIT tools, and interoperability… there are foundational pieces that are especially important, including: 

• EHR and Registry functionality 

• HIE access  

• Risk stratification algorithm (ideally based on multiple criteria including chronic conditions, utilization, pharmacy, behavioral health, and social needs) 

• Predictive analytics (if you can get it!)  

Continuous Improvement via Workforce Development and Training 

Never stop growing…! As you make these infrastructure investments, don’t neglect to ensure Care Managers are learning. Professional development and Care Management Training, as well as collaborative learning opportunities with other Care Managers is absolutely key to ongoing improvement. The outcomes they are contributing to are your feedback loop to the health and care of your patients, and increasingly to your own financial ability to thrive.  

HealthTeamWorks, a national nonprofit organization exists to solve complex healthcare problems. Contact us for support in APM performance, building a population health infrastructure, strategic alignment, risk readiness, and workforce development. 

solutions@healthteamworks.org