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Specialty Case Management

Our Specialty Case Management programs boost ROI and empower members to make informed decisions and work with their physicians to better manage their health.

KEPRO is Effectively Targeting Three Major Healthcare Cost Drivers.

On a per capita basis, healthcare spending is expected to grow almost 70%, from $7,800 per person in 2008 to $13,100 per person in 2018.1 That’s why aggressive case management targeting cancer, heart disease, and end of life care is critical to minimizing costs while maximizing the quality of life for every member. KEPRO has a unique approach centered on your members and your ROI. 

Oncology Case Management

Cancer care is projected to increase over 39% by 2020, to $173 billion. Average treatment cost per patient can range from $14,000 with no surgery or chemotherapy, to $123,000 for patients receiving both surgery and chemotherapy; the overall average cost per patient is $49,000.2 

EARLY IDENTIFICATION IS CRITICAL FOR HELPING MEMBERS AND CONTROLLING COSTS. 

Provider and/or member self-referral is the ideal way to identify members early. KEPRO works with our clients to develop effective marketing campaigns that educate members and providers about the program. In addition, KEPRO’s data analytic tools synthesize demographic and laboratory data; medical, behavioral, and pharmaceutical claims; pre-defined oncology triggers; and health risk assessment responses. We also apply our trigger list, comprised of ICD-9 codes, to utilization management data to identify cases for Oncology Case Management. Our clinical professionals call each member’s treating physician to verify the diagnosis. Then they make sure that the care prescribed is evidence-based as well as appropriate for the type and stage of diagnosed cancer. This ensures that the member gets the therapy with the most significant impact on quality of life and cost. 

Our Specialty Case Management programs boost ROI and empower members to make informed decisions and work with their physicians to better manage their health. 

OUR CUSTOMIZED APPROACH EMPHASIZES THE UNIQUE NEEDS OF YOUR MEMBERS. 

Our member-centric program begins with understanding the medical, behavioral, functional, cultural, educational, spiritual, and economic needs of each member, as well as family/caregiver preferences and concerns. A primary case manager (PCM) assesses the scope and complexity of the member’s healthcare needs using standardized guidelines, proprietary tools, and compassionate open discussion. 

Our comprehensive assessment supports desired outcomes in five areas: 

  1. Primary/specialty care access 
  2. Quality of life and behavioral health 
  3. Cancer and symptom therapy 
  4. Complication management 
  5. End of life planning 

The PCM reviews the assessment findings with our oncology care team (medical director, behavioral health professional or social worker) and develops a focused care plan that targets needs most suited to intervention. We also review the plan with the member, family/caregiver, and physician before finalizing. This approach promotes positive clinical results and the highest ROI. We routinely reassess each member’s care plan and interventions and nurture behavior modification through continued care calls to help ensure that members successfully achieve their program goals. 

OUR COMPASSIONATE INTERVENTIONS FOCUS ON HOLISTIC CARE. 

KEPRO’s comprehensive, member-centric solution takes into account that individuals facing cancer often have emotional issues and co-morbid conditions to address. We help members understand their treatment plans, follow dietary recommendations and medication regimens, and keep follow-up appointments. We also involve family and caregivers, so that they can understand the member’s condition and wishes, and offer support and encouragement. 

Our focused interventions are specifically designed to maximize each member’s quality of life, reduce/manage depression, and optimize pain management. They are realistic, based on the physician’s prognosis and member wishes. Interventions also focus on families and caregivers who must deal with their own feelings or depression as they care for their loved ones. 

Interventions include:

  • Providing member and family education and support
  • Assisting members with developing effective self-management plans
  • Coordinating healthcare needs and services across the continuum
  • Coordinating and facilitating use of community/employer services/resources
  • Serving as an advocate to each member/family
  • Collaborating with each member’s physician/healthcare team
  • Enabling safe care and home environments
  • Facilitating end of life planning to include transition to hospice 

KEPRO’s aggressive Oncology Case Management solution decreases treatment costs, improves overall health outcomes, and preserves each member’s dignity. 

Heart Failure Case Management

Heart failure is responsible for 11 million physician visits each year, and more hospitalizations than all forms of cancer combined. It contributes to approximately 287,000 deaths annually. Approximately 5 million Americans of all ages suffer from heart failure. Approximately 500,000 new cases are diagnosed each year. Nearly 1.4 million persons with heart failure are under 60, with the annual incidence of heart failure approaching 10/1,000 after age 65.3 

MANY MEMBERS ARE NOT AWARE OF THEIR CONDITIONS. 

They often mistake common symptoms for normal signs of aging. This contributes to a sudden death rate of 6 to 9 times greater than that of the general population. Because there is no cure for heart failure, effective condition management is critical. 

WE COLLABORATE WITH PHYSICIANS TO ENSURE THE BEST OUTCOMES. 

KEPRO’s heart failure program is modeled after the infrastructure and principles of our oncology program. It incorporates the nurse counseling process of assessing members and collaborating with each member’s physician. We focus on planning and implementing appropriate interventions to address gaps in care, while promoting effective cost management tactics. We also ensure that the targeted results and outcomes of the program are aligned with heart failure guidelines. Case management plans are created and adjusted to the physician’s defined stage of failure and functional classification. 

OUR PROGRAM FOCUSES ON CLEAR AND ACHIEVABLE GOALS. 

Maximizing quality of life while minimizing avoidable costs are our primary objectives. The key is enabling members to modify their behaviors and lifestyles, while improving skills critical to managing a chronic condition. We continuously assess the member’s clinical, social, economic, and behavioral health status. Then we use motivational interviewing to facilitate behavioral change and compliance. Our case managers also monitor medication compliance and efficacy, and recommend home monitoring devices to assist higher risk members. 

How We Protect and Empower Your Members. 

  • Ensuring medically prescribed treatment plans align with evidenced-based protocols
  • Removing member barriers to compliance with prescribed treatment plans
  • Educating members on their conditions, complications and coping with stress
  • Helping members develop effective self-management plans
  • Managing all co-morbidities that may diminish quality of life and outcomes
  • Facilitating healthcare power of attorney, advance directives, and end of life planning

Advanced Illness/End of Life Management

The average cost associated with end of life care over the last two years of life is $58,000. Approximately 60% of all deaths occur in the hospital, yet most patients express a preference to die at home. And although hospice programs typically provide palliative care in the last six months of life, the median length of hospice stay is 22 days. Approximately 35% of patients die within the first 7 days of hospice admission.

END OF LIFE PROGRAMS CAN DECREASE COSTS BY APPROXIMATELY 33 PERCENT. 

Cost for members enrolled in an end of life program average $12,500 compared to $20,000 - $30,000 for members not enrolled.4 End of life programs remove barriers to hospice early access and provide alternatives that do not forgo life-sustaining treatment. 

These programs also ensure that patients discuss their preferences with family before they become seriously ill, and that providers and family members respect their wishes. KEPRO’s advanced illness/end of life program does just that by providing valuable resources for decision support, quality of life management, and dignity. Our interventions are designed to maximize each member’s quality of life, reduce/manage depression, support advanced illness care decisions, provide advance directive education, and optimize pain management. 

WE’RE ENSURING MEMBER WISHES ARE RESPECTED AND FOLLOWED. 

Our case managers work with members to identify care wishes and communicate them to loved ones while still able. They are trained to understand and respect cultural and spiritual beliefs in order to better support members and families. We help members get their affairs in order, so they can maintain a degree of quality of life/peace of mind in their remaining days. We help each member address difficult topics, such as living wills, do not resuscitate orders, palliative care, medical powers of attorney, organ donation, and hospice care. 

KEPRO BRINGS A COLLABORATIVE APPROACH TO DIFFICULT DECISIONS. 

We ensure that effective pain medication is prescribed by the physician and consistent with condition/tolerance and advance directives. The case manager coordinates with the member’s physician when pain management issues arise. We also help the member and family transition to hospice and provide emotional support. Additional program components include: 

  • Preventing provider service fragmentation and advocating end of life decisions
  • Fostering shared decision making, comprehensive education and discussion
  • Advancing care planning to meet personal goals and address family needs
  • Educating and supporting to the patients and their families
  • Providing 24x7 access to their palliative care manager 

KEPRO has a Proven Record of Improving Outcomes for Everyone.

Our Specialty Case Management programs achieve documented improvements in financial, clinical, and member satisfaction outcomes. Savings are attributed to direct member claim cost reductions and cost avoidance activities, from removing barriers to compliance, and educating of members and their families. Savings primarily result from a decrease in avoidable use of healthcare resources, such as a decrease in admissions/readmissions and use of the emergency department. Average ROI may range from 3:1– 5:1, based on client-specific variances. One significant outcome is an increased percentage of members who comply with their treatment plans. For example, adherence to chemotherapy treatment best practice guidelines could reduce costs by $3,000 per case, saving approximately 3% of total costs. 

We also provide members or families with satisfaction surveys to comment on how effectively the program empowered them to work more collaboratively with their physicians and better manage their total health. We consistently achieve a greater than 90% satisfaction rate. 

Given the emotions and difficulty of every situation, it’s a benchmark we take great pride in. 

[1] Dartmouth Atlas of Health Care, April 2011. 

[2] Fitch and Pyenson, 2011. Benefit Designs for High Cost Medical Conditions. Millman Res Report. 

[3] American Heart Association. 

[4] Annals of Internal Medicine, July 3, 2012. 

Find an Answer

Please describe KEPRO data security that ensures member information is protected.

As an organization that is charged with storing and transferring Protected Health Information (PHI), KEPRO is bound by HIPAA regulations, and is accustomed to managing the security and privacy of PHI. KEPRO currently exchanges data successfully and confidentially via secure encrypted means in support of all of our federal, state, and local government programs, and with commercial clients.

KEPRO has been implementing and supporting systems that require medical record, data security, and transmission for more than a quarter of a century, and has always placed primary importance on using systems that allow for fast and efficient connectivity, while still providing the highest level of data and system security. Our proven internal and external policies and protocols ensure compliance with state and federal laws and regulations, as well as any additional security measures you may require.

We have a stringent KEPRO Comprehensive Confidentiality Plan that governs our processes. KEPRO’s Privacy Officer, Security Officer, and the Compliance Officer have ultimate responsibility for oversight of the processes and procedures contained in the KEPRO Comprehensive Confidentiality Plan.

KEPRO's system is secure. Our information systems are secured by an in-depth strategy that utilizes multiple layers of operational, management, and technical controls to protect KEPRO assets. We also employ software programs designed to prevent unauthorized use by staff or outside entities.

All KEPRO information systems employ common security controls such as Firewalls, Anti-virus, Role Based Access, FIPS 140-2 Encryption for mobile devices, and the requirement of strong passwords. Information system users are assigned a security role based upon access requirements relevant to their positions and information/program privileges.

The HIPAA Security Rule requires entities to implement information systems that control access to healthcare and related systems. KEPRO adopts a subset of NIST 800-53 Rev 3 Security controls to maintain compliance with HIPAA. Based on these security standards, KEPRO mitigates risk to its Information system by focusing on such controls as:

  • Log-In Security. HIPAA security requires the use of secure User IDs and the use of passwords. KEPRO requires multiple account authentication processes within its information systems to verify the identities of our end-users. KEPRO's policy requires strong passwords that are changed frequently.
  • Access Control. HIPAA requires one of the following: Context Based Access, Role Based Access, or User Based Access. User Based Access is part of the Log-In Security component. KEPRO's Role Based Access gives individual users access relevant to their function in the organization.
  • Audit Trail. HIPAA requires the use of an audit trail to identify who accesses PHI. KEPRO systems track those who change the patient record, the date and time the record was modified, and the specific information changed. The system includes a read only audit trail that captures each time a system user views a case.
  • Session Time-out. KEPRO information systems account for session inactivity by locking screens after 10 minutes of inactivity.
  • KEPRO's physical space is secure. KEPRO’s computer, telephone, and hardware systems are located in climate controlled rooms with fire-suppression and electronic locking system. We allow only authorized access to the room.
  • KEPRO focuses training on confidentiality and security issues. All KEPRO employees undergo rigorous training on security and confidentiality of PHI. We have successfully provided this training to all staff regardless of their respective roles/duties.

KEPRO Headquarters

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777 East Park Drive, Harrisburg, PA 17111
Toll-free: 800.222.0771
Phone: 717.564.8288
Fax: 717.564.3862