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FAQ Public And Commercial
What is the value of integrating your medical management programs?
An integrated approach of utilization, case, chronic care, and specialty case management programs, such as oncology and maternity management, is the most cost effective way to manage the health of your total population. Specifically, an integrated approach eliminates barriers by addressing all of the physical and behavioral healthcare needs of each participant rather than treating one issue or condition at a time, ignoring the total health and treatment needs of each participant.
Early Identification and Referral
An integrated approach allows KePRO to perform a single source claims analysis so that we can identify the appropriate program and interventions based on the member's overall healthcare needs. Each member works with one case manager to address all care needs, without the duplication of efforts and confusion arising from multiple calls to different programs.
To ensure that care management programs have the most impact, you must first understand the current and future risks of your individual population. KEPRO performs predictive modeling using claims data to identify potential participants with utilization patterns and conditions that may benefit from care management interventions, including participants with multiple providers, poly-pharmacy, or gaps in care.
KEPRO's predictive modeling can improve the targeting of care management programs by:
- Predicting the recipients most likely to incur high costs
- Determining recipients in this high cost group who have avoidable costs
- Identifying specific gaps in care that, with appropriate intervention, will reduce disease progression and exacerbations and reduce care costs.
- Identifying specific cost drivers that will benefit from focused programs, such as oncology, heart failure, or advanced illness.
KEPRO also uses our utilization management program to identify and refer candidates who would benefit from other care management programs. Using triggers embedded into our proprietary medical management system, we can identify these participants early, often when they are still in the hospital, and engage them in our more intensive programs. Being able to engage participants early and often while they are still hospitalized increases participation rates and further demonstrates the benefits of KEPRO's integrated care management approach.
We also use biometric data captured in our wellness program to identify and engage candidates for more intensive intervention, including those who are at increased risks for chronic and other conditions. And with our proprietary, integrated medical management platform, we seamless move members to appropriate programs as their care needs change.
If you use a separate vendor for utilization, care management and wellness, the lack of communication among vendors or delay in the identification process costs you money. More than 20 percent of persons discharged from the hospital are readmitted within 30 days of discharge (Centers for Medicare & Medicaid). And an April 2013 study published in The Annals of Emergency Medicine found that a quarter of the patients discharged from Boston Medical Center during the first half of 2010 resulted in at least one emergency department visit within a month after the patients left the hospital. And 54 percent of those visits to the emergency department did not lead to a readmission, but increase health care costs.
Addressing Total Health Care Needs
KePRO’s integrated approach to care management improves total health and well-being by addressing each participant's comprehensive health needs. We are successful because we employ a primary case manager model and conduct thorough assessments based on participant needs.
Primary case manager (PCM) model
Studies demonstrate that patients who identify with one person (such as a personal physician, or case manager) have significantly better health outcomes than those who see multiple providers for their healthcare (De Maeseneer JM, De Prins L, Gosset C, et al. Provider continuity in family medicine: Does it make a difference for total healthcare costs? Ann Fam Med. 2003; 1:144-8.). Assigning a registered nurse to serve as each participant’s PCM enables us to provide better care coordination, increases our ability to address all conditions and co-morbidities, and facilitates strong relationship-building with both participants and their providers.
We assign a PCM to further assess each participant’s health and enroll the individual in the appropriate care management program. We assess general quality of life and physical and behavioral health and all co-morbidities (including mental health), to identify barriers to compliance, health literacy related to condition and prognosis, and readiness to change. For hospitalized participants, we identify barriers that prevent the participant from complying with the discharge to home and/or medical treatment plan as prescribed by the provider, including medication adherence, follow-up office visits, etc. And for those identified as candidates for our chronic care management program, we conduct condition-specific assessment as warranted.
We reassess participants at varying intervals, and move them seamlessly (using our proprietary medical management system) to other programs as their care needs change. The PCM retains primary responsibility for coordinating all interventions in the participant’s case, and works closely with other healthcare team members, such as a maternity case manager, to support the participant’s short and long term needs.