Category: Uncategorized

Today’s health plans face many challenges, including increased competition due to factors including the abundance of options available to beneficiaries, an aging population, rising member expectations, regulatory pressure, and a complex and diverse demographic. One critical way health plans differentiate their efforts to improve care is by providing an exceptional member experience.

However, when engaging members with multiple chronic and complex healthcare conditions— such as many members on Medicaid, Dual Eligible Special Needs Plans (DSNP), or pediatric populations under the Comprehensive Family Life (CFL) program—the challenges become even more formidable.

Challenges to Member Engagement for Complex Populations and Chronic Conditions

The clinical needs of Medicaid populations with chronic illnesses are diverse and often require coordination across multiple specialties. For pediatric populations, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings are required for early identification of health issues. Care managers must fulfill the needs of providers, staff, families, and regulations while also overcoming operational hurdles that create inefficiencies and high administrative loads. To deliver compassionate and comprehensive care, care managers require more advanced systems to manage larger caseloads more effectively, reduce frustration, and streamline their vital role in enhancing care quality.

Member communication

Effective communication is crucial for engaging members in their care plans regardless of their situation. Yet, ensuring a smooth experience across multiple channels—from in-person visits to digital platforms—can take time and effort, particularly with high-risk populations. Integrating communication channels, accounting for member preferences, and making the care experience easier to navigate requires a thorough understanding of member resources, behaviors, and preferences, as well as advanced technology.

Social Determinants of Health

Social Determinants of Health (SDOH) significantly impact members living with multiple chronic illnesses. Effective member engagement for complex populations goes beyond traditional clinical interventions and requires partnerships with community organizations and a robust data-sharing infrastructure to address SDOH like housing instability, food insecurity, and education.

Regulatory Reporting

Government programs have strict regulatory reporting requirements that care managers must follow. These regulations continuously change, and updates come at an increasing frequency while the penalties for non-compliance get steeper. As federal and state agencies push for greater transparency and interoperability, care managers must adapt to these administrative changes. This can distract from their focus on care, especially when dealing with legacy systems.

Disparate Technology Systems

Many member engagement solutions operate in silos, making it difficult to access a unified view of members to coordinate care, communicate effectively, and tackle administrative tasks. Interoperability between systems is critical to providing coordinated care and a personalized and effective member experience.

The complexity of care, integration of social support, and the barriers to communication for the populations in greatest need require a nuanced approach to service delivery and the technology that supports it.

 

Digital Care Management Goes Beyond Just Communication

Digital care management is an innovative approach to healthcare that transcends traditional communication methods, offering more engaging, informative, and proactive interactions that are crucial to member engagement of complex populations. At its core, digital care management solutions offer services including:

• Health education articles tailored to the individual’s clinical needs and based on specific care programs to help members understand and manage their health conditions.
• Interactive assessments that enable real-time data sharing about a member’s health status, keeping care managers informed and allowing them to be proactive in their care strategies.
• Encouragements and motivational messages that help members become advocates for their health and foster improvement through ongoing discussions.
• Automated reminders that help care managers and members stay on track with critical activities and milestones, ensuring that important care management tasks are not overlooked.
• Omnichannel features such as chat and secure text messaging that facilitate real-time, bidirectional communication, making it easier for members to connect with their care teams and vice versa.
• A dashboard view of each member that allows a care manager to have a unified view of their situation, interactions, and health journey.

Digital care management, as delivered by the HealthEdge® Wellframe® member experience platform, represents a shift from episodic, intermittent support to a continuous, holistic care model. It leverages technology to extend the reach of care teams, enabling them to engage more fully with high-risk members and significantly impact engagement:

• With the Wellframe platform, members average 258 touchpoints per month with their care teams.
• Wellframe drives significant increases in Medicaid member engagement without increasing staff. A HealthEdge analysis of one health plan showed a rise from 3 touchpoints per case to nearly 200, resulting in 14 days engaged per month.
• With Medicare members, another analysis showed that care managers increased total touchpoints from 3 to nearly 500, resulting in 15 days engaged per month for six months.

With digital care management, members are empowered to take an active role in their health journey, supported by the tools and resources necessary for effective self-management and improved outcomes.

Care-Wellframe: Integrating Engagement and Care

Care-Wellframe is an integrated solution that combines HealthEdge’s premier care management platform, GuidingCare®, with Wellframe. The solution transforms how health plans approach digital care management, removing barriers for the most complex use cases with one solution rather than trying to solve care and experience with separate solutions.

This packaged integration makes the following possible:

• Seamless data sharing between GuidingCare and Wellframe that eliminates redundant data entry and the inefficiency of using separate systems.
• Instant access for both care managers and members to clinical education materials, benefit plan details, and community resources related to Social Determinants of Health (SDOH) in one system for quick, relevant referrals.
• Prioritization, through alerts and insights, of members who most urgently require outreach, streamlining the care management process and personalizing content to their needs.
• Tracking care plan adherence directly from the member’s profile, and an online chat feature accessible through the interface.
• Omnichannel communication which allows care teams to reach members through their preferred channels.

 

With Care-Wellframe, members benefit from personalized interactions and are supported by trusted care managers who empower them to make informed health decisions. Digital care management enables care managers to improve clinical outcomes, engage meaningfully with members, and reduce administrative tasks—especially when dealing with high-risk populations such as pediatrics or those covered by Medicaid or DSNP.

Next-Generation HealthCare Member Engagement

To effectively manage member experience for populations with complex healthcare needs and enrolled in government programs, it is essential to have a comprehensive approach that combines integrated, next-generation technologies with compassionate, person-centered care.

Health plans must efficiently scale care management teams to support more complex use cases. Streamlined member engagement integrated with care management leads to better health outcomes, membership growth, higher member satisfaction, and better Star ratings. With Care-Wellframe, health plans can meet these vulnerable groups’ clinical, social, and regulatory needs while fostering continuous engagement and support.

Learn more about how your organization can improve member engagement and care management with key insights from our 2024 Consumer Survey.

 

 

 

 

In an era where healthcare demands are rising exponentially, and health plans are stretching their budgets, increasing the capacity and efficiency of care management is becoming a key area of focus. As care management models evolve, care teams are increasingly asked to do more with less—and are facing a growing cognitive burden while doing so. Wellframe’s digital care management solution empowers care teams to extend their reach and serve broader member populations using real-time insights.

Empowering Care Teams with Digital Solutions

Care teams today face unprecedented pressures from multiple angles. They are tasked with managing complex patient needs while grappling with administrative responsibilities and high workload volumes. Wellframe’s digital care management solution offers a lifeline by delivering real-time member insights and enabling care teams to reach multiple members at once.

Using the Wellframe platform, health plans can reach and engage rising-risk members before they become high-risk.

Member Empowerment

Empowering members to take control of their own health and wellness is at the heart of Wellframe’s approach. With over 70 care programs that enhance traditional care management models, members are equipped to manage their health proactively.

The platform offers a self-service resource center that features clinically reviewed articles relevant to members’ health and wellness needs. They also have access to benefits information written in plain language to help improve understanding and utilization. These tools promote self-advocacy and health literacy for health plan members, enabling them to become more independent and confident in navigating the healthcare system.

Workflow Efficiency

The Wellframe solution helps significantly reduce the cognitive load on care teams through several features that streamline their workflows while enabling them to increase care management capacity.

1. Dynamic Decision Support:

Intelligent alerts and insights recommend high-impact interventions, helping care teams prioritize and act swiftly on critical issues.

2. AI Summarizing Capabilities:

Streamlined summaries facilitate quick, informed decision-making, allowing care managers to focus on member-centered care rather than administrative tasks.

3. Digital Assessments:

Digital surveys and assessments remove the administrative burden associated with telephonic health risk evaluations, making the process more efficient and less time-consuming. Members can respond at their convenience, with fewer concerns about information privacy.

4. Many-to-One and Group Action Options:

These tools enable care teams to reach multiple members with the same message templates, ensuring that more members receive timely and necessary healthcare communications.

Expanding the Reach of Care Management

Traditional care management methods, such as telephonic outreach, often fall short of effectively engaging members. Long phone calls not only frustrate members but also hinder care managers from practicing at the top of their license. One large Blue Cross Blue Shield plan encountered these challenges head-on.

The health plan’s existing care management processes made it difficult to scale resources and engage with more members, necessitating a modern solution. Using Wellframe, care managers were able to leverage digital channels to increase member touchpoints and establish trusted relationships with members, leading to improved engagement and better health outcomes:

• 91% Increase in Successful Calls: Digital interactions established trust, making members more likely to answer phone calls from care managers and increasing preparedness for those calls.
• 2x Increase in Active Caseload Size: Care managers using Wellframe supported significantly more members than with traditional care management alone.
• 6x Increase in Member Interactions: Digital adoption led to more frequent and meaningful engagements with members.

Measuring Value and ROI of Digital Care Management

The value of digital care management goes beyond immediate savings on care costs. Using digital care management, health plans achieved measurable outcomes in the following areas.

1. Medical Cost Savings

Engaging more members through care management leads to better health outcomes and reduced medical costs for larger populations. By preventing complications and ensuring timely interventions, health plans can save substantially on medical expenses. In one study, health plans were able to save $1,923 per member over a three-month period.

2. HR Cost Avoidance

Expanding care team capacity through digital tools means that care managers can support more members without increasing headcount. This leads to significant HR cost avoidance and better resource allocation.

3. Higher HEDIS/Star Scores

Improving health plan quality scores translates to federal bonus payments (in the case of Medicare) and increased member enrollment across all lines of business. Higher quality scores also enhance the plan’s reputation and competitiveness.

Digital care management is not just a technological advancement; it’s a strategic imperative for modern healthcare organizations. By empowering care teams, enhancing workflow efficiency, and expanding the reach of care managers, solutions like Wellframe enable healthcare organizations to deliver better care at scale.

For healthcare leaders looking to innovate and drive efficiency, integrating digital care management into their operations is a crucial step. It offers a pathway to improved health outcomes, better resource utilization, and a more competitive market position.

Ready to transform your care management approach and achieve better health outcomes for your members? Discover how Wellframe’s digital care management solutions can enhance efficiency, reduce administrative burdens, and improve member satisfaction.

Watch our on-demand webinar, “Activate Today’s Medicare Member: Effective Engagement Strategies” at any time on our website.

 

As the healthcare industry evolves, health plans face increasing pressures from virtually every area of their businesses. Care management teams are particularly challenged to address these pressures, as they are often charged with managing the most vulnerable and complex members. This is forcing many payers to pursue digital care management best practices to support their traditional care management strategies. Some of the key driving forces behind these innovations include:

• The role of care managers continues to expand as multiple business and payment models emerge.
• Healthcare consumers’ expectations for personalized digital engagement continue to rise.
• Regulatory requirements become more complex and burdensome to follow, while clinician burnout reaches an all-time high.

By transforming traditional care management teams into digital care management teams, payers hope to bring benefits to all stakeholders: members, care managers, and the health plan itself.

However, it’s important for payers to understand that this transformation is not just about implementing modern technology solutions, like HealthEdge GuidingCare® and HealthEdge Wellframe™. It must include a comprehensive approach to organizational change management that ensures the full business objectives are met.

Understanding the Need for Change

The journey toward digital care management begins with recognizing the necessity of change. Health plans must understand why the change is important and align it with the organization’s vision and mission. Without aligning on change management goals, efforts may falter from the outset. Organizations must foster a pervasive culture of change across all levels, involving not only clinical leadership but also IT, data, and community-based partners. Change must be embraced by the entire organization, supported by multilevel activation and champions to push the strategies forward.

Leveraging HealthEdge for Digital Transformation

HealthEdge GuidingCare is a comprehensive care management platform designed to help health plans better support some of their most complex populations. Health plans have found that partnering closely with HealthEdge facilitates seamless integrations and implementations. This partnership can also enable health plans to successfully transition new member populations onto their GuidingCare system and integrate with newly acquired health plans.

For health plans looking to embrace digital care management capabilities, Wellframe offers a comprehensive digital member engagement solution. Health plans that adopt Wellframe experience transformed care delivery, providing nurses with a powerful tool to engage members more effectively. This transition is not without its challenges, as nurses must adapt from traditional telephonic methods to a new digital interface. However, the benefits soon become evident: streamlined processes, increased member engagement, and improved clinical outcomes.

Wellframe’s app enables care managers to provide tailored, member-centric support, including medication reminders and educational content. The efficiency gains are substantial, with care managers able to deliver interventions and follow-ups much faster than through traditional methods. The app also allows for asynchronous communication, giving members the flexibility to engage with their care at their convenience.

The integration of GuidingCare and Wellframe (Care-Wellframe) creates a comprehensive digital care management ecosystem. This care management interoperability ensures that all functions work seamlessly together—without having to swivel between disparate systems. Health plans can leverage this integration to achieve scale without having to expand their care management teams. Automation and digital tools become force multipliers, enabling health plans to provide consistent and high-quality care to their members.

Best Practices for Change Management

Transforming care management involves more than just implementing new technology; it requires a cultural shift within the organization. Health plans must foster a culture that embraces change and transformation while maintaining regulatory compliance and performance measures. This begins with understanding the organization’s capabilities and identifying opportunities for improvement based on data insights.

For example, health plans can leverage data to track clinical quality, resource use, and customer service measures, setting strategic priorities that align with member outcomes. This alignment ensures that everyone in the organization, from customer care to pharmacy teams, understands their impact on these measures. Training and education play critical roles in empowering staff to contribute to the organization’s goals.

Successful change management involves several best practices:

• Communicate the Why: Over-communicate the reasons for change to ensure all stakeholders understand and buy into the vision.
• Empower Early Adopters: Engage early adopters with input from the team to drive transformation.
• Simplify Architecture: Streamline systems to reduce unnecessary touchpoints and ensure seamless interoperability.
• Foster Collaboration: Encourage collaboration across departments and with external partners to solve problems collectively.
• Embrace Continuous Improvement: View change as an ongoing process of improvement rather than a one-time event.

Measuring Care Management Success

Success in care management transformation can be measured in various ways. For executive leaders, it’s about return on investment (ROI). For case managers, success means effective member interactions and efficient workflows. For administrative teams, it’s about minimizing errors and ensuring regulatory compliance. Health plans must be willing to measure success in different ways than traditional care management metrics, acknowledging both wins and failures as opportunities for growth.

For example, health plans can hold stakeholders accountable to timelines, encouraging collaboration, and giving permission to fail. By creating an environment where staff can raise their hands and seek help, organizations can foster a culture of continuous improvement and innovation.

The Future of Care Management

Automation and digital solutions are today’s key to the future of care management. Care management teams must adapt to the changing healthcare landscape by doing more with fewer resources. Automation and digital care management enable care managers to scale and reach more members, which improves both care manager and member satisfaction.

Integrating digital with traditional care management is a complex but necessary journey for health plans. HealthEdge GuidingCare and Wellframe are at the forefront of this transformation, providing health plans with both the technology and the change management support services necessary to navigate the complexities of today’s healthcare environment. As a result, every stakeholder wins:

• Members: Engage with care managers on their own terms via preferred communication channels, experience more personalized customer service, and experience better health outcomes.
• Care managers: Access real-time clinical and social data to effectively meet members where they are, with the right care and support.
• Health plans: Find new ways to scale care management teams to reach more members, contain costs, improve performance measures (Star ratings), and remain competitive.

To learn more about how HealthEdge can help transform your care management team from traditional care management to digital care management, read our case study, “Next Generation Care Management at Denver Health Medical Plan”.