Lessons Learned: Five Reasons Care Management Programs Fail
As the healthcare environment evolves, healthcare providers struggle with the redesign of their care management programs to deliver the more stringent outcomes demanded. Care management is at the heart of identifying and working with patients at risk. It is charged with coordinating the internal care team and external providers to establish a care continuum that ensures smooth transitions and judicious use of scarce health care resources. New processes must be developed in conjunction with the historical functions of utilization review, denials management and discharge planning. With changes to the payment landscape and the transparency of outcomes, care management programs must have a broader focus on readmissions, length of stay, emergency room visits, appropriate level of care and indirect costs.
Differences in terminology and definitions only add to the confusion. In an effort to minimize confusion, care management within this article is defined as, “A process designed to assist patients and their support systems in managing their medical/social/mental health conditions more efficiently and effectively. Case management and disease management are included in this definition. ”1 FTI has worked with numerous healthcare providers to design or redesign their care management programs based on desired outcomes. This process starts with defining the organization’s goals and objectives and requires understanding of what type(s) of outcomes the organization is expecting from these activities. Through years of experience, FTI has identified the top five reasons many programs struggle and how to assist our clients with the delivery of efficient patient care.