Care Management: The Engine Driving Value-Based Care

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to Value-Based care Insights, I'm your host Daniel Marino. When people think about value-based care they often focus on the contracts. Elements of shared savings working with the payers, what does downside risk look like? How do we maximize quality incentives? but really value-based care is more than that right? We've talked about this time and time on the program and it's really evolved more out of the contracts and transformed into more of an operating model supporting the culture shift into value based care. And organizations that have consistently been successful in value based care have created this operating model that is capable of changing patient behavior aligning physicians, focusing on real performance outcomes, like reducing avoidable utilization or certainly improving quality and just delivering more higher level, more efficient care to our patients. But time and time again when you think about that operating model, it really comes down to care management as the engine that drives that operating model. And oftentimes organizations really struggle with how to put in place effective high performing care management to really maximize the goals of value based care. And a lot of times what they struggle with is how to create model that is financially sustainable. Most of the times CFO's struggle with investing in care management because they don't see that immediate return or putting in place care management programs to support the physicians. Or ensuring that we're focusing on the right area of outcomes around value-based care, and that's really highlighting the patient experience and creating efficiencies that result into lowering our total cost of care.

Well, I'm really excited today to talk to a leader who has helped numerous organizations build these capacities I'm sorry these capabilities around care management. We are joined today by Patty Resnik an accomplished healthcare executive with extensive experience in care management population health, quality performance and of course value-based care. Throughout Patty's career she has led transformative initiatives that have really improved these outcomes and really have met the goals of creating a stronger patient centered healthcare experience. Patty, welcome to the program.

 

Patty Resnik:

Thanks Dan, it is really great to be here. I want to start off thanking you for having me on your show. I'm honored to be here I appreciate you taking the time to spotlight care management because it is such a vital component of value-based care.

 

Daniel Marino:

Absolutely, I agree. So when we think about organizations, what do you see as some of the biggest challenges that health care organizations are having right now in putting in place effective care management?

 

Patty Resnik:

Yeah that's a great question, Dan. And I think that the one that rises to the top for me is the overall leadership in care management. The competencies that are needed in that role has really evolved over time. it not only encompasses case management, care coordination, professional standards. But now these leaders need competency in quality in revenue cycle and in compliance because of all the regulatory components. And especially quality because quality is what drives the outcomes in the reimbursement in value-based care so I've seen that evolve overtime and it can be challenging to find maybe not one leader with all those skill sets but really those skill sets need to be on the team.

 

Daniel Marino:

Right. So when you when you think about care management, I often say that you know value-based care, if that's the car right and you have this nice shiny car around value-based care the engine and how fast you go is really care management. So when we think about care management what are some of the key factors that you see are sort of these best practice models? Is it leadership is it the protocols? Is it having you know a decentralized model of care management where you have of care managers in the clinic office? If you were to kind of think through what are those key best practices or the key highlights that drive effective care management?

 

Patty Resnik:

Yeah, I am in my experience, and I've had the opportunity to work in executive leadership roles in care management, and in my experience the optimal structure, first of all we'll start with structure, is having a structure that's fully aligned to the strategic plan of the organization. And I think the optimal way to do that is to have that reporting structure under one leadership umbrella, right? You get not only do you get the strategic alignment it gives you the ability to create documentation that is centralized, so that everyone caring for that patient can see that documentation. You can leverage automated workflows. The collaborations amongst the team because it's under one leadership model becomes very efficient very effective. And you get you gain these staffing efficiencies because as you have staffing vacancies or leave of absence, you can easily shift your team without having to go to another leader to try to negotiate the priorities of care management. So it really makes for an optimal care management infrastructure, and then you can put the data infrastructure in place within that to really drive your outcomes, clinically financially patient experience wise.

 

Daniel Marino:

Right, it all brings it together. So when you think about that structure does care management, is that best practice to have care management sit under a population health umbrella? Should it be sitting in a clinically integrated network or an ACO type structure? Or maybe should it report up to nursing? right as a as a direct extension of nursing? What have you seen work best is that structure?

 

Patty Resnik:

Wow, that really hits home. You know I think that as I moved from acute care into population health, I think that the optimal framework sits within population health. And I say that because in population health you see the patient or the member across the continuum of care. So the episode in the hospital typically very short period of time. Very important to manage that episode of care appropriately. But then when that member patient leaves the system and your accountable either through an ACO or risk arrangement or whatever arrangement that may be, your care management team is engaged with the patient and family and the providers for a much longer period of time. So to me it makes sense that that infrastructure be under population health. Of course working very very collaboratively with all of the other leaders that care management touches.

 

Daniel Marino:

Yeah I agree with you. I think it allows for more of an enterprise based approach and when you think about care management right? And sort of really peel back the onion, there's so many different distinctions of care management. so you'll have case management and the activities that occur her in the acute setting care management that touches transitions of care we may have care management that is aligned with the ambulatory setting. But let's not forget the patient navigation and the patient outreach component which is a critical feature of care management. When you when you work with organizations do you often see a lot of those components of care management? is it is it really is a decentralized or is it centralized or what's the approach that you've taken with organizations to kind of pull all of those components together into an effective care management platform?

 

Patty Resnik:

Well as I mentioned in the IT really depends on the organization how they are how they are structured right and some organizations will decentralize not only the care management functions. But when you think of care management in the broader context of value-based care you really need to pull in utilization management to that social work is included within that right? So what about the decentralization all of the workflows for those professions are interrelated. So my approach is always to say under one umbrella is where you're going to get the most efficient workflows, the most effective collaborations and the team begins to appreciate more how their individual workflow affects the greater picture. And how important it is to embed into their into their normal everyday operations. A quality mindset understanding what is driving the reimbursement and value-based care and how their work relates to that. So within that context I think care management is much more than case management care coordination. You cannot forget about the UM component and social work. And sometimes what happens is UM gets tucked up under revenue cycle. And it's and it's then totally separated from the care management work. But when you think about it UM is doing very important work, denials and appeals. The care management team needs to know if the patients in a in a episode isn't currently in a denied status. Or if there are carve outs and delays. And the reasons behind that may help in in the appeal process. So my approach is always under one leadership infrastructure and completely collaborative with every other infrastructure that those vital departments touch.

 

Daniel Marino:

If you're just tuning in, I'm Daniel Marino you're listening to value-based care insights. I'm here talking with Patty Resnik on care management. And we're diving into the best practice approach of care management and sort of the effective outcomes related to care management services. Patty a couple months ago, I had this conversation with some leaders around care management. It was a health care organization that had been involved in in value based care has a pretty effective clinically integrated network. And they waffled back and forth between care management that was decentralized, so they went to one extreme where they had care managers in the clinic to where they brought them back into more of a centralized model and now they're sort of working on a on a hybrid model. And one of the things that they found coming out of this,and it was really interesting I'd love to hear your thoughts on this, was in decentralized model they felt like their care managers weren't effective because they became part of the clinical team and didn't focus on care management but they focused on direct patient care. But yet when they switched to the centralized model they felt like they weren't as effective as they could have been or they should be with working directly with the physicians and with the patients. Where are your thoughts in terms of that type of a structure versus you know centralized decentralized or hybrid model?

 

Patty Resnik:

I can definitely appreciate that scenario. And in my experience when it is decentralized what can happen and what often does happen, is the case managers the social workers start taking on different roles and responsibilities that are really on the fringe of their scope, or perhaps not even related to the scope, or there's a short stamping situation and they get pulled away into other things. And pulls them away from their core competency. So by pulling it centralized I think that one of the effective models here is to engage with the service line leaders to engage with the nursing leaders, and then to really put a compliment of case managers and social workers in their area and work together to say although they report to this centralized model, where we can ensure they are up to date on all the regulatory requirements that the role encompasses, and that's a lot of requirements so ensuring that everybody's up to date on. We can ensure that they are trained in quality and they understand how to drive value-based care and reimbursement all the while supporting you. So you will have your dedicated team of people, we will take care of the training and the education and the workflows all working together to achieve the organizational strategy and goals. So that is key. You can't centralized the team and then not be collaborative and integrated into the clinical workflows right? That that component is absolutely absolutely critical.

 

Daniel Marino:

Yeah, I agree with you it has to be embedded into the workflow and I think that's where you're starting to see a lot of CDI work uh continuous documentation improvement where you're working through the workflows and evolving those workflows that has care management embedded in it.

 

Patty Resnik:

I'll add a comment there that Dan, just a little personal story. I worked with a surgeon who this really resonated with him right? He wanted to know who's my who's my case manager? And his philosophy was always every patient needs a daughter, he said. I love the daughter, I love when the daughter comes into the office because I know that she is going to have a list, and she's going to be telling me all the problems, and what needs to be done. And when I give her my list, I know it's done. So who's my person here that's gonna do that for me?

 

Daniel Marino:

I love it, yeah. And that’s so true too, right? When you have the caregiver that's a daughter that is really attuned to helping their helping their parents or somebody else in their family, you know you know you're going to drive to results. Let's talk about the finance side of this for a second. And working with a lot of the CFOs, many you know as some CFOs, I wouldn't say all, but some CFOs see investment in care management as kind of this never ending black box of investment right? And you know to a certain extent you're investing in care management in personnel,in the technology, with the goal of obviously producing some type of results so maybe reducing avoidable emissions or reducing you know some of the ER visits and so forth that are driving to performance. But in a lot of cases we're investing in population health through care management with the idea that we're trying to either minimize or eliminate things for happening in the future. And that's really hard to incorporate into an ROI model. So in your experience maybe in in your past leadership roles how have you worked with the CFO's to create that alignment to make sure that you have gotten the right level of a budgetary funding or investment in care management so you're able to drive the results that you need to drive?

 

Patty Resnik:

You are spot on Dan with this question. And it is absolutely critical for case management leaders to have a relationship with the CFO. So I had a beloved uh CFO who I learned so much from him. And that relationship was very important. I needed to understand from his perspective how does he look at success? And I was able to also offer to him this is what case management critical role is this is what they do, this is how they appropriately reduce length of stay, this is how the UM team on the front end prevents denials from ever getting to the back end and you're sending clean claims out the door faster. So what measures would be the appropriate measures to say the UN team is working effectively and we should invest in this team. Because we're overturning denials before the patient ever leaves the vet. The claims are going out the door clean, quicker, we're getting reimbursed fast. What are the key measures of success for case management? The focus on reducing the extended length of stay addressing carve outs and delays in the system and facilitating patient flow so that patients can move seamlessly through the system and you can move patients who need to get in more quickly.

 

Daniel Marino:

What you're what you're really saying is you're taking a very focused approach of aligning certain care management programs with some immediate performance incomes from a finance standpoint that are going to reduce costs, improve some of your value-based purchasing opportunities, as well as then your performance and your value-based contract. So, you know it probably doesn't cover all of the costs related to care management. But I think it's a pretty good start if you could frame it around those three or four key areas and really take the model in the and framing it around that short term ROI.

 

Patty Resnik:

Absolutely Dan. And that that is a very good you know way to frame that for sure. And involving the quality leader in the organization to say, to ensure that care management understands this is where we are on the performance on the CMS value-based programs. Here are the programs that case management and UM and social work directly impact so making sure that the CFO understands it is through the workflows that we're investing in case management social work UN that these value based programs were performing better.

 

Daniel Marino:

Well in one of the areas that when we go in and help organizations think about you know enhancing their care management, one of the first areas we look at is really around their transitions of care program. Because I'll tell you there's a lot of hospitals that still rely on the discharge nurse to come to create the care plan and they really you know have align their transitions of care around the discharge planning, which is which it isn't right? It doesn't even do it you know any any type of justice there. And when you think about the investment in transitions of care there is a direct revenue opportunity right because they have to follow up with the ambulatory and primary care you know in in a short amount of time after they get discharged. But if you're able to provide that connection of care management with the caregiver, not even so much the patient, but with the care with the caregiver in a way that the caregiver fears come feels comfortable. Boy you're able to cut through a lot of the challenges related to s at the emergency department or just answering you know challenging questions that the caregiver may have, just making the caregiver as well as the patient feel comfortable. That right then and there is a huge area of ROI opportunity.

 

Patty Resnik:

Oh absolutely Dan and that is what case managers, care managers, social workers do so well. This is their work and I have great respect for the people who are on the front lines doing this work. That trusting relationship with the caregiver, and the patient, but particularly the caregiver. Who's the support person that is going to really take this discharge plan and make sure they get to the appointment on time. They have their medications at home, they're the point of contact in the home so that when home health is coming that they're there to understand what is the plan now that we are we are no longer at the hospital. I'll talk a little bit just for a second about hospital care at home. Because hospital care at home, there's many benefits. I had the privilege of standing up a hospital care at home program. I think one of the greatest benefits is the care transition occurs at admission, and what happens is the care is totally in the patient's home. So the care team comes in the patient's already home the caregiver is already there, they are completely embedded in the care experience and that transition then is the team leaving and the caregiver and patient are much more comfortable because they've been involved the entire time.

 

Daniel Marino:

Yeah and but it's really a comprehensive approach where you need to think about that evaluation with the caregiver recognizing aspects of the patient's home and whether it's conducive to really the right level of recovery. And even to your point once the care team leaves ensuring that you have that right level of support I think is really key too

 

Patty Resnik:

Oh absolutely. it gives you a view into the social determinants of health that you cannot get at the hospital. You are in the patient's environment and you really understand here are the things that we need to help engage the patient and their caregiver in addressing before we part.

 

Daniel Marino:

Well, and the social determinants are becoming, have become such a critical aspect of driving care management performance. I want to dive into one other area, and that is artificial intelligence. You know there's so much data out there and I really feel like in the work that we've done with organizations, that being able to use AI to aggregate this data as a tool for care manager, I really feel as a game changer. And you know for years care managers would have to go through all of this information have to call up the providers have to figure out ways of aggregating this information to make sense out of it before they can even have a conversation with the patient of the caregivers. I think AI is really gonna change that in in a way of being being able to expedite all of this data and information into usable, actionable insights. Where do you think AI is going in support of care management?

 

Patty Resnik:

I think it is a very exciting future for care management leveraging AI. You know when I think about it, and I use it today in just helping to analyze the regulatory environment and what the care management team is required to do. But being able to very quickly generate structured templates, educational materials for patients. Perhaps leveraging agentic AI. You have patients where you have risk modeling and you know they're high risk for readmission, the patient family want to go home possibly using an agentic AI agent to engage with the patient in the home and send back data to the care management team so they're aware of any potential situations that may need to be addressed when the patient's at home. So I think that there are so many exciting possibilities integrating AI into care management.

 

Daniel Marino:

Yeah I agree and I think to your point I think we've only started to scratch the surface there in terms of the impact that we're going to see on care management performance. Well Patty, I want to thank you for coming on the program, an exciting topic care management obviously is one of these topics that's near and dear to my heart. I commend you on all the work that you're doing with organizations across the country on improving care management services. If any of our listeners are interested in maybe connecting with you or finding out a little bit more about this topic, can you share your contact information?

 

Patty Resnik:

Sure, easiest way to connect with me is through LinkedIn. So connect with me on LinkedIn and I'm happy to follow up on the conversation.

 

Daniel Marino:

Wonderful. Well thank you again Patty for coming on the program, really appreciate it.

 

Patty Resnik:

I appreciate the time Dan. And again, thank you for spotlighting the critical component of care management in value-based care, I could talk about it all day long.

 

Daniel Marino:

My pleasure. And I want to thank our audience for tuning in. Until our next insight, I am Daniel Marino bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners