Case Study: Elderplan

Elderplan Overcomes Fragmented Care Management with GuidingCare®

In an increasingly fragmented care management landscape, Elderplan sought a modern solution to stay compliant and efficient amid evolving regulatory demands. Headquartered in Brooklyn, New York, this not-for-profit health plan organization serves 26,000 members, processing over 2 million claims annually. However, the challenge lay in adapting to stringent regulations from both the New York State Department of Health (DOH) and the Centers for Medicare and Medicaid Services (CMS), compounded by the need for enhanced risk scoring and data interoperability.

Challenges Faced by Elderplan

1. Regulatory Compliance:

• Need for agile adaptation to increasing regulatory demands.
• Mandated behavioral health benefits for Medicaid Advantage Plus (MAP) plans.
• Impending ONC Final Rule requiring enhanced data interoperability.

2. Operational Efficiency:

• Difficulty in capturing and reporting required data elements.
• Inefficiencies caused by manual processing.

The Solution: HealthEdge’s GuidingCare® Platform

Elderplan chose HealthEdge’s GuidingCare^® due to its agility, flexibility, and ability to streamline care management across the entire healthcare continuum. Key features include:

Configurable Workflows:

• Adaptable to evolving healthcare regulations.
• Integrated with over 75 unique vendors.

Operational Efficiencies:

• Automated GPS nurse assessment scheduling.
• Real-time new enrollee alerts.
• Systematized evaluation processes.

Enhanced Interoperability:

• Seamless integration of medications into the care management platform.
• Nightly data results for next-day service plans.

Results Achieved

GuidingCare® enabled Elderplan to achieve significant improvements, including:

Time and Cost Savings:

• Recouping losses through automation.
• Improved accuracy and efficiency in evaluations.

Improved Member Experience:

• Consistent scripts and member-centric workflows.
• Holistic member view through integrated medications.

Compliance and Reporting:

• Standardized, consistent reporting to avoid sanctions.
• Enhanced support for audits and interdisciplinary team care planning.

Elderplan's transition to GuidingCare® has proven successful in addressing fragmented care management, ensuring compliance, and enhancing operational efficiency.