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How Safety Net Health Plans Can Advance Care Management

Safety Net Plans face unique challenges as they work to connect and engage with hard-to-reach populations to improve the health of the communities they serve. These challenges include:

  1. Working with groups of members requiring very complex care plans
  2. Inefficient and costly processes resulting from manual, fragmented workflows
  3. Siloed systems that make it difficult to access up-to-date, accurate member data
  4. Collaboration with social services groups and systems that don’t talk to each other across organizations
  5. Extensive tracking and reporting that creates more administrative burden

All of these challenges come amidst the backdrop of even broader health insurance industry challenges, such as workforce shortages that are driving up costs of labor and care. Regulatory changes are requiring payers to adapt processes and technology to meet new guidelines. Evolving business models are creating new opportunities while driving demand for greater business agility. And today’s healthcare consumer expectations are rising to match their everyday retail experiences.

These challenges were echoed by a recent survey of nearly 300 health plan leaders serving Medicaid, Medicare, Duals, and Marketplace members. The survey showed the top two challenges were managing costs & creating new operational efficiencies. The top goals for the year were increasing quality, enhancing regulatory compliance, and improving provider relationships. The primary steps to achieve these goals were to better align business and IT goals, make significant investments in innovation, and modernize technology.

These findings point to the fact that health plans are ready to start their digital transformation as they bring IT and business stakeholders together and invest in innovative solutions to move the business forward. Now is the time for payers to become digital payers.

What is a digital payer?

Digital payers are identified by five attributes that enable them to rise above the competition and lead the way to better outcomes across the entire healthcare delivery system. Digital payers focus on:

  1. Leveraging digital tools to improve end-user and member centricity
  2. Achieving higher levels of quality to deliver better outcomes for members and communities
  3. Increasing business transparency, breaking down siloes and improving exchange of information
  4. Advancing customer service by empowering teams to support inquiries with next-generation solutions
  5. Constantly reducing transaction costs through automation and connectivity

These are the payers that will emerge as leaders through this dynamic period of change and truly improve outcomes for every patient and stakeholder across the healthcare ecosystem.

Story of a Digital Transformation: VillageCare

VillageCare is a community-based, not-for-profit organization serving nearly 20,000 seniors, people with chronic care, continuing care, or rehabilitation needs in New York. VillageCare set out on a journey to transform business processes with a next-generation digital foundation that could:

  • Support clinical and business operations through integrated work processes
  • Support a data-driven organizational culture
  • Support VillageCare’s healthcare clinical partnerships through data integration
  • Expose data to members and clinical partners using data standards
  • Use best-in-class applications that integrate to create a seamless systems environment

VillageCare wanted to implement a digital foundation that would enable mission-critical clinical workflows in a value-based, patient-centric, and fully integrated ecosystem. Their ecosystem of connected SaaS solutions powers mission-critical areas of the business including:

  • Care Management
  • Utilization Management
  • Appeals & Grievances
  • Authorization Portal
  • Business Intelligence
  • Population Health
  • Member Services

Impactful Results with HealthEdge

By developing this digital foundation with HealthEdge, VillageCare experienced transformational experiences for stakeholders.

  • Members:

Prior to VillageCare’s digital transformation, health plan members struggled through disconnected touchpoints to navigate the process of finding a provider, determining eligibility & costs, utilizing available benefits, & communicating with their care team. As a digital payer, VillageCare streamlined processes by shifting these touchpoints to easy-to-use, self-service tools that consumers expect – delivering all in a single access point.

VillageCare uses digital solutions from GuidingCare® to simplify workflows and improve access to data and information. As a result, they can deliver a frictionless member experience and increase member engagement and satisfaction, while ultimately improving health outcomes.

  • Providers

Many of VillageCare’s providers were frustrated by time and manual effort required to gain insight into patient benefits, inefficiencies in the process of seeking authorizations, multiple systems required to get answers, inaccurate claims payments, and managing reimbursements.

VillageCare eliminated provider abrasion by delivering instant access to real-time patient benefit and claims data through GuidingCare. They provided connectivity and access to collaboration tools that enable steps to be completed and information accessed in a single solution.

  • Member Services

Prior to their transformation, VillageCare’s member service teams experienced inefficiencies that negatively impacted the member experience, including wasting hours searching for member & provider information, navigating multiple software systems, and uncovering inaccurate and out-of-date information.

VillageCare transformed member services engagement by providing self-service tools and access to accurate, real-time data for members.

  • Care Managers

Prior to the organization’s digital transformation, VillageCare care managers were challenged by disparate technology systems, disconnected workflows, and manual workarounds. They spent countless hours hunting for member & provider information, attempting to connect with at-risk members, tracking authorizations & compliance, and accessing and completing care plans & educational programs.

VillageCare empowered care managers by putting real-time important member data at their fingertips in one location, so they can focus on building trust with members and optimizing care outcomes. They now automate authorization and utilization management workflows. This improved the experience for the care managers and improved efficiencies. They also use unified care team communications and real-time care alerts to improve health outcomes.

  • IT Teams

At VillageCare, the pre-transformation experience for the IT team involved navigating communications across multiple vendors, managing updates across multiple systems on different schedules, dealing with disconnected workflows and broken integrations, addressing regulatory changes with outdated systems, and advancing business and IT alignment.

After transforming the organization with next-generation solutions from GuidingCare, the VillageCare IT team could operate more efficiently and deliver on business needs more effectively. Now, they have greater flexibility to collaborate with the business and use available tools to ensure technology investments are achieving business objectives. The modern solutions are designed with interoperability as a priority, leveraging HealthEdge’s robust API framework and industry standards, such as FHIR. As a result, the IT team can optimize how their workforce is deployed, improve access to data for end users, and quickly and easily adapt technology to address emerging business opportunities and regulatory changes.

Stuart Myer, Chief Information Officer at VillageCare shared, “Our digital transformation journey has truly changed the way our teams operate, improving the experience for members, providers, member services, care management, and IT. It has allowed us to become a data-driven organization that operates more efficiently and creates better outcomes for the community we serve.”

Learn more about HealthEdge’s care management software GuidingCare.