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In any organization, maintaining a culture of integrity and accountability is a top priority. At HealthEdge, one of the ways we uphold these values is by providing a hotline for employees, vendors, and customers to report issues and raise concerns. An effective whistleblower program empowers individuals to report unethical behavior, misconduct, or violations of company policies without fear of retaliation.

We’re highlighting five key reasons why offering Speak Up is crucial for employees, vendors, and customers:

1. Facilitates Transparency and Trust

Speak Up promotes transparency by encouraging employees, vendors, and customers to report unethical behavior, misconduct, or violations. This transparency helps build trust among stakeholders and fosters openness and honesty, which are essential for a thriving organizational culture.

2. Protects Whistleblowers and Builds Confidence

Individuals who report unethical behavior may fear reprisal. Speak Up provides a safe and confidential channel for reporting violations, ensuring whistleblowers are protected from retaliation. This protection builds confidence among employees, vendors, and customers, empowering them to speak up without fear of negative consequences.

3. Prevents Legal and Financial Risks

Organizations can mitigate the threat of legal and financial risks by recognizing inappropriate activity early. Speak Up provides an avenue for employees, vendors, and customers to report issues promptly, enabling HealthEdge to take corrective action before the situation escalates. This proactive approach helps prevent costly legal battles and protects the organization’s financial stability.

4. Promotes Accountability and Ethical Conduct

A robust whistleblower program holds individuals and the organization accountable for their actions. Knowing that unethical behavior at HealthEdge will be reported and addressed encourages responsible conduct among all stakeholders. This culture of accountability ensures that HealthEdge operates with the highest ethical standards, reinforcing our commitment to integrity.

5. Enhances Compliance & Drives Continuous Improvement 

Feedback received through the Speak Up program can identify compliance violations and areas for improvement. By addressing these issues, HealthEdge can refine internal processes and policies, leading to comprehensive improvements across the organization. This continuous improvement fosters a culture of excellence and ensures adherence to relevant laws, regulations, and industry standards.

Speak Up is an indispensable tool for fostering integrity and accountability within HealthEdge. It ensures transparency, protects whistleblowers, prevents legal and financial risks, promotes accountability, enhances compliance, drives continuous improvement, and strengthens corporate culture. Speak Up demonstrates our commitment to ethics, integrity, and responsibility. Prioritizing this program sets HealthEdge apart as an ethical leader in the healthcare industry, dedicated to creating a better future for all stakeholders.

When it comes to optimizing care management, it’s common to hear stories about care managers losing valuable time playing phone tag, and members feeling frustrated because they don’t know when or how to get in touch with providers when they need to. Digital care programs can give health plan members access to resources and interventions when it’s most convenient for them.

Wellframe’s whole-person digital care programs are designed to engage members by giving them the knowledge they need at the right time, empowering them to make informed health decisions. Leveraging digital care programs, care teams can build trusting member relationships that can improve outcomes and retention.

What Are Digital Care Programs?

Digital care programs leverage technology to streamline communication between care teams and health plan members. This approach helps streamline workflows and improve efficiency by cutting down on the time it takes for care teams to contact and get key health and wellness information from members. Consequently, care managers see a 2x increase in caseload size, and 6x increase in member interactions—without sacrificing quality.

The Wellframe solution currently offers more than 70 digital care management programs covering acute and chronic conditions, including diabetes management, weight management, hypertension, maternal health, and more.

Benefits of Digital Care Managemen

• Improved Care Outcomes: Members enrolled in the Diabetes care management program reduced their blood sugar readings by up to 25%. Members in the Hypertension care management program lowered their blood pressure by up to 9%.
• Complex Care Support: Members with multiple conditions who had access to Wellframe reported 33% fewer readmissions. Additionally, senior members using Wellframe reported 29% fewer Emergency Department (ED) visits.
• Cost Containment: Health plans using Wellframe digital care programs reported $641 in per member per month (PMPM) savings. Members using Wellframe also reported a 29% increase in utilization of preventive services, which can help lower long-term healthcare costs.

Designing for the Sweet Spot with Self-Directed Learning

The average lifespan in the U.S. is 79 years, but the average healthspan is only 63 years. This means many Americans spend about 20% of their lives unhealthy. Wellframe aims to bridge this gap by targeting high-risk and rising-risk members who would benefit from proactive and ongoing engagement.

For example, the Maternity digital care program encourages members to attend pre- and postpartum care visits and sends information relevant to where they are in their pregnancy. A Care Transitions program can provide extra support to members after a hospital discharge to reduce readmissions and complications.

Member-Centric Approach

Motivating members to actually use digital care programs involves a combination of educational content, a user-friendly interface, and interactive elements. Many members are open to self-directed care opportunities, and just need access to reliable information and guidance. Whole-person digital care programs provide trustworthy and relevant health information alongside care team communications, reducing the need to rely on potentially misleading online sources.

This approach not only makes health resources more accessible but also helps alleviate the cognitive burden on providers, extending their reach and effectiveness.

Creating Engaging & Interactive Content

Starting and sustaining healthy habits begins with removing obstacles to better choices. Our content is designed to make it easier for members to adopt healthier lifestyles by offering practical advice and actionable steps.

Visualization and Integrations

Visualization tools and integrations with health technologies help members set achievable goals and track their progress. Based on the care program they’re enrolled in, members are prompted to input information such as their weight, blood sugar, blood pressure, and step counts every day. The information is stored in the app and presented to users in easy-to-read graphs and other visuals.

Interactive Learning and Related Content

Wellframe digital care programs include [NB1] articles with multiple-choice questions to actively engage members. For instance, a blog about incorporating more vegetables into your diet might ask whether canned vegetables are a healthy food choice. The article may also be followed by an article on healthy recipes that are quick to prepare.

Linking Knowledge to Action

Whole-person digital care programs emphasize how members can make small improvements to their health and wellness by providing specific, supportive content. Some examples include:

• Substance Use Disorder: Promoting healthy habit formation and mindfulness while reducing feelings of shame and stigma.
• Perimenopause Support: Highlighting available care choices and agency in treatment.

For healthcare payers dedicated to making a meaningful impact on their members’ lives, Wellframe offers an innovative, engaging, and effective approach. Wellframe is not just a digital health management tool—it’s a visionary solution crafted to transform healthcare delivery and the member experience. By integrating advanced technology, evidence-based content, and empathetic interactions, we’re setting new standards in care management.

Experience the future of digital care management with Wellframe. Watch our on-demand webinar to learn effective health plan strategies for expanding staff reach and enabling them to meet members where they are to drive better member engagement, satisfaction, and clinical outcomes.

[Watch the webinar]

 

I think we’ve phased videos out of care programs for the most part [NB1]

In today’s competitive healthcare landscape, operational efficiency isn’t just a goal—it’s a necessity. Health plans are constantly seeking ways to streamline their processes, reduce overhead, and improve care delivery. Provider Data Management (PDM) for health plans is an often-overlooked solution that can improve efficiency and performance.

In a recent Becker’s Healthcare podcast, we explored how optimizing PDM can be a game-changer for health plans. With this blog, we dive deeper into addressing common challenges and highlighting how advanced PDM solutions, like those from HealthRules Payer, can revolutionize healthcare payer operations.

Benefits of leveraging Provider Data Management (PDM) For Health plans

Provider Data Management is the practice of collecting, validating, and maintaining accurate information about healthcare providers. This information can include demographics, specialties, locations, and network affiliations. Maintaining an accurate repository for provider data is crucial for several reasons:

• Improved Care Delivery: Offering updated provider data ensures that members can find the right care at the right time, leading to better health outcomes and greater trust.
• Operational Efficiency: Streamlined PDM processes reduce administrative burdens, allowing staff to focus on more strategic tasks.
• Compliance and Risk Management: Keeping provider data up-to-date helps in complying with regulatory requirements and mitigates risks associated with incorrect information.

Common Challenges in Provider Data Management

Health plans often face significant challenges in managing provider data. Outdated or inaccurate information can lead to claim denials, member dissatisfaction, and increased administrative costs. Common issues include:

• Internal Data Silos: Information is often stored in disparate systems, making it difficult to validate data and maintain a single source of truth.
• Reliance on Manual Processes: Many health plans still rely on manual data entry and updates, leading to errors and workflow inefficiencies.
• Lack of Real-Time Updates: Delays in updating provider information can result in outdated data being used for critical decisions.

5 Ways Health Plans Are Leveraging Advanced Provider Data Management Solutions

Advanced PDM solutions, like those offered by HealthEdge, can address these challenges head-on. These are five ways our current health plan customers are leveraging PDM at their organizations:

1. Ensuring Data Accuracy and Completeness

HealthEdge’s PDM system ensures no data loss by providing 100% coverage for provider demographics, customer-specific UDT, and benefit network data. It offers real-time provider API services for any missing, incomplete, or inaccurate provider cases. This ensures that health plans always have access to the most accurate and complete data.

2. Streamlining Processes to Increase Automation

The platform is configurable to align with the customer’s master data identification defined on HealthRules Payer. This streamlines data verification processes, increasing automation to reduce overheads and inefficiencies. By automating routine tasks like data verification, staff members can focus on more strategic activities and drive overall efficiency.

3. Enhancing Data Enrichment and Workflow

HealthEdge’s PDM solution provides data enrichment through validation checks and easy-to-use workflows. The platform leverages a centralized framework with more than 300 built-in quality checks and third-party validations (like NPPES) that address standardization and attestation. Its modern web application, with a native workflow module, allows customers to define, automate, and track changes—ensuring high data quality and consistency.

4. Facilitating Seamless Distribution and Integration

The PDM platform supports configurable data distribution and native Core Administrative Processing System (CAPS) integration. This includes a self-service module to set up, schedule, and deliver data extracts. Additionally, it supports real-time API, event-based distribution, and seamless integration with HealthRules Payer, allowing data to flow smoothly across systems.

5. Leveraging Modern SaaS Platform Features

HealthEdge’s PDM is a modern SaaS platform with web-based workflows. This cloud-native software offers high availability, unlimited scalability, seamless upgrades, and role-based access. It also features a customer-extendable data model, providing the flexibility to meet the unique needs of each health plan.

Key Differentiators of HealthEdge Provider Data Management for Health Plans

In a highly fragmented market, the HealthEdge PDM solution stands out in four key areas:

• Provider Master Identifier: Distinctly recognizes unique providers and organizations based on specific needs and business requirements.
• Data Mastering with Prebuilt Match and Merge Rules: Effectively handles and maintains data sourced from various channels, with users able to review and address conflicts.
• Low or No Code Framework: Generative AI-enabled framework allows users to easily set up and map source channels with minimal coding.
• Observability Dashboard: Provides insights into processing status, duration, and data quality from various source channels.

In an industry where efficiency and accuracy are paramount, optimizing Provider Data Management for health plans can be a significant driver of success. By leveraging advanced PDM solutions like those offered by HealthEdge, health plans can overcome common challenges, streamline operations, and ultimately deliver better care to their members.

Are you ready to transform your health plan’s workflows to improve efficiency and accuracy?

Read our case study, “HealthRules® Promote Empowers Medica Health Plan to Streamline Processes” to learn more.

 

Over the past four years, healthcare payers have faced immense pressure to adopt new technologies that aim to increase member engagement, improve clinical outcomes, and control costs. But it can be a challenge to make the most of your health plan’s digital solutions and achieve the return on investment (ROI) you planned for at implementation. Wellframe delivers value to health plans by extending the reach of your existing resources and offering in-app suggestions on how to do more with the tools and insights available.

Below are 5 key ways the Wellframe solution can improve ROI for healthcare payers.

1. Improving Chronic Condition Management

Every year, the U.S. spends about $4.5 trillion in health care expenditures. 90% of this goes toward treating members with chronic and mental health conditions. For members living with one or more chronic conditions, staying on top of health and wellness can be a challenge.

Wellframe addresses these issues by providing a robust digital solution. Diabetic members utilizing the Wellframe app have experienced a remarkable 25% reduction in their blood sugar readings, while members with hypertension have seen their blood pressure drop by up to 9%. These impressive statistics underscore the platform’s ability to facilitate effective chronic condition management, leading to better health outcomes and reduced healthcare costs.

For more on this topic, explore our Member Impact Report.

2. Supporting High-Risk Members Throughout Their Journeys

High-risk members require comprehensive, high-touch support to navigate their complex healthcare needs. Wellframe ensures these members are not left behind. The app offers personalized tasks on daily checklists tailored to individual clinical requirements, including medication reminders, biometrics tracking, and educational content. Moreover, members can securely communicate with their care teams via the app, providing a seamless and effective way to manage their health.

Learn more about supporting high-risk members in our Medicaid Maternal Health Resource.

3. Streamlining Staff Workflows and Increasing Capacity

Traditional care management methods often involve time-consuming tasks such as making phone calls, leaving messages, and conducting questionnaires over the phone. Wellframe revolutionizes this process by enabling care managers to reach more members efficiently. Through the app, care managers can send secure messages to multiple members simultaneously, allowing members to respond at their convenience—leading to a 6x increase in member interactions. Digital surveys and assessments can also be sent directly to members’ smartphones, saving time, ensuring greater security compared to traditional phone calls. By leveraging Wellframe’s digital tools, care managers can double their caseload size, and increase successful phone calls by up to 91%.

Read more about streamlining staff workflows in our Staff Efficiency Case Study.

4. Proactively Identifying and Addressing Health Barriers

Members often feel hesitant to discuss sensitive personal information over the phone. Wellframe mitigates this issue by providing a secure messaging feature where members can comfortably share their concerns and ask questions. Additionally, the platform allows care managers to uncover social determinants of health through digital surveys. With real-time notifications when members complete assessments and automated flagging of high-risk members, care managers can prioritize their outreach effectively, addressing health barriers proactively.

Discover effective strategies for identifying and addressing health barriers in our guide.

5. Increasing CMS Star Ratings and Member Satisfaction

Achieving higher CMS Star Ratings is crucial for health plans aiming to enhance their reputation and secure more rebates—and increasing member satisfaction is a major contributor. The Wellframe solution plays a pivotal role in these endeavors by supporting health plans in delivering timely and effective care, reducing preventable readmissions, and improving the patient experience. Members benefit from a single digital health management platform that provides them with the relevant information and support they need, precisely when they need it. The Wellframe member app boasts a 4.7 of 5 star rating on the App Store, demonstrating its use to members. Proactively focusing on member satisfaction can help health plans increase their CMS Star Ratings, ultimately resulting in greater financial incentives.

Explore our Star Ratings Guide to learn more about improving your scores.

Wellframe stands as a transformative force in the realm of health plan management, offering a comprehensive digital solution that addresses the multifaceted needs of members and care teams alike. By improving chronic condition management, supporting high-risk members, streamlining staff workflows, proactively identifying health barriers, and enhancing CMS Star Ratings, Wellframe delivers exceptional value to health plans. Embrace the future of healthcare with Wellframe and witness firsthand the profound impact it can have on your organization’s efficiency and member satisfaction.

Ready to take the next step? Connect with us today to discover how Wellframe can revolutionize your health plan management.

 

The healthcare industry is experiencing unprecedented change. New technologies in care management are now widely available to help healthcare payers streamline care delivery, improve operational efficiencies, and automate manual processes.

How are industry shifts impacting the requirements of effective training for care management staff?

Sontz-Morrison: There are several factors influencing the demand for more and accessible staff training opportunities in functional areas like care management. The first is, without a doubt, workforce shortages and high turnover rates. The World Health Organization (WHO) predicts a shortage of 10 million health workers by 2030. This ongoing workforce shortage across allied and behavioral health, long-term services, nursing, primary care, and women’s health is placing an immense pressure on clinicians and support staff to “do more with less.” Despite these constraints, maintaining quality care remains paramount.

Second, the regulatory environment in healthcare is constantly changing. Health plans must remain updated on Medicare and Medicaid regulations while also focusing on improving pricing transparency and healthcare access. Though it can put more administrative burden on care teams, staying up-to-date on new guidelines is essential to ensuring compliance and remaining competitive.

Lastly, the consumer demand for personalization is shaping how we need to develop our training. Modern consumers have come to expect personalized experiences in most aspects of their lives—including their healthcare. These expectations are pushing healthcare payers to adopt new technologies that are transformational. Training for any of these technologies, which can require staff behavioral changes and high adoption rates to be effective, must be fool proof.

The integration of new technologies, evolving regulations, and current workforce dynamics significantly impacts the requirements for technology onboarding and training at health plans. Health plan staff must enhance their knowledge and stay current with regulations to streamline their processes without adding extra layers or underutilizing talent. Without proper education, new tools can become cumbersome for users, causing issues like technology underutilization, administrative errors, missed regulatory deadlines, or missed opportunities to improve member outcomes.

What is GuidingCare University, and how can it support health plan staff?

GuidingCare® University (GCU) is a self-service learning and development solution designed to empower customers and end-users by giving them control over their success. GuidingCare® users even receive alerts before new training modules go live to improve visibility. With GCU, staff have access to comprehensive training on GuidingCare content, technology, optimization, and best practices.

GuidingCare University was designed to serve staff working in a variety of roles, including utilization management, nurses, medical directors, appeals and grievance staff, and population health professionals. By targeting all staff that utilize GuidingCare software, GCU ensures comprehensive training and knowledge sharing across teams. This leads to optimized solution usage, breakdown of internal siloes, and streamlined daily operations.

What are some of the benefits to leveraging GuidingCare University training?

• Continuous Learning: New courses are added quarterly and as needed based on product feature enhancements, ensuring that there are no delays due to a lack of instructors or updated information.
• Real-Time Updates: Training modules go live at the same time as product updates, providing insights and best practices whose value can be passed on to members.
• Increased Efficiency: Employees can access and revisit trainings at any time, reducing time spent searching for answers and getting stalled by not knowing who to ask.
• Improved Accessibility: Training modules are broken into “bite-sized” 5-20-minute segments, making them easy to watch and understand even with a busy schedule. This is particularly beneficial for care managers who balance training with patient care.
• Self-Empowerment: On-demand training modules ensure employees never have to feel like they don’t have enough training to perform their roles effectively. Trainings can also be used alongside organizational onboarding to give new users a comprehensive resource.

Which metrics do health plans use to measure the impact of on-demand training from GuidingCare University?

Key performance indicators (KPIs) play a crucial role in evaluating the effectiveness of training tools like GCU. In addition to tracking metrics like messaging and touchpoint volume, health plans can assess training effectiveness in other ways. Increasingly, organizations are using badge programs and certifications to demonstrate employee skills and understanding of a digital solution.

To help healthcare payers understand how their employees are using the modules and absorbing important information, GCU will be incorporating three new tools into the platform:

• Knowledge checks that pop up throughout training videos.
• Pre- and post-training quizzes to gauge understanding and identify areas for improvement.
• Reporting that tracks video engagement, including watch duration, completion rates, and most rewatched content.

Recently, a customer interview revealed that employees found GCU training streamlined their comfort with the GuidingCare solution. New employees also reported the GCU training modules enhanced their overall onboarding process and helped them feel empowered to fulfill their roles successfully.

The Bottom Line

Today’s healthcare environment demands a responsive and adaptive approach to staff training, especially when it comes to using new technologies. Effective training solutions are not just an option for health plans, but a necessity. By providing continuous learning opportunities and real-time updates, GuidingCare University ensures that staff are well-equipped to meet the dynamic demands of the healthcare industry—leading to better performance, improved member outcomes, and more efficient operations.

Read our brochure, “Empowering Health Plans to Advance Care Management with GuidingCare”