Health Plans Can Utilize Technology to Optimize Care Utilization and Collaboration in Post-Acute Care Settings

As the U.S. healthcare system moves towards value-based care models for Medicare and more susceptible members, care providers and skilled nursing facilities are engaging in additional risk-based contracts with health plans and payers. While this can ultimately be beneficial to health plans by driving down costs with more focus on holistic and preventive care approaches, the learning curve to members may pose some challenges.

Managing increased utilization and costs, collaborating with providers on care coordination in post-acute settings, and engaging members about health plan benefits to better manage health are all necessary steps to drive value. The right technology to optimize care utilization may hold the key to overcoming these obstacles for better outcomes for members at lower costs.

1) Managing increased utilization and costs

Increased utilization and chronic disease management are ongoing concerns for health plans and payers. As a result, there is the constant pursuit of new tools and strategies to help manage acute and emergency service utilization and chronic health conditions to improve outcomes and lower costs for members.

A factor that has made this management effort more difficult is the ongoing impact of delayed care during the COVID-19 pandemic. The disruption caused by people choosing to put off preventive or routine medical care and treatments has resulted in more complicated needs and more costly care encounters. Health plans and payers are still grappling with how to help providers and members manage the complexity of care, especially in the management of chronic diseases and disease progression.  

Frequent utilization of emergency services is another challenge.  When members go to the emergency department (ED) instead of an urgent care center or their primary care provider (PCP) for the same treatment and attention, increased costs can be incurred. It’s becoming more important than ever to get deeper insights into specific at-risk populations and episodes of care delivery.

Solution:

Health plans and payers must leverage better solutions to identify members at a higher risk of hospitalization and adverse outcomes. More data sharing and collaboration is required between payers and providers to effectively monitor groups or individual patients as they move throughout the care continuum, especially members managing multiple chronic conditions and those continuing on to post-acute care settings like skilled nursing facilities (SNFs). Seeking out technology that pulls together information from multiple data sources to improve both risk stratification and risk adjustment is key. 

This effort could help with access to the insights needed to manage care for an individual within a specific population.  A smart admission, discharge, transfer (ADT) notification solution that can synthesize multiple risk factors and dispatch only the most critical notifications to the point of care is needed so that payers and providers may collaborate more effectively to identify, stratify, and adjust risk, improving engagement, member services, and, ultimately, clinical and financial outcomes.

2) Collaborating with post-acute care providers on care coordination

Reducing readmissions after a hospitalization, especially for Medicare and vulnerable members, depends on close collaboration with post-acute care providers. Existing collaboration challenges due to fragmented data exchange can lead to disruptions in care, problems with care transitions, higher readmissions, longer stays at SNFs, and redundancies in care delivery.

Payers may also need to educate the post-acute partners in their network on the benefits and best practices for working through contracts with two-sided risk. Ensuring collaboration and proactive communication between case managers and care teams can facilitate streamlined care delivery, drive value, reduce readmissions and length of stay in post-acute care settings, and support better outcomes and reduced costs.

Outdated information technology infrastructure may also be a factor impeding the ability of healthcare partners to work together effectively. Dispatching alerts about health encounters and ensuring visibility across disparate health information systems is an obstacle for care coordination.

Solution:

Smarter technology networks can facilitate collaboration across different electronic health record (EHR) systems, convey urgent notifications regarding members at greater risk, and deliver crucial information like discharge summaries, care plans, and medication profiles directly to post-acute providers at the point of care.

This can improve coordination, care delivery, cost savings, and care transitions – all critical for health plans to support better collaboration across the entire continuum of care.

3) Engaging members about health plan benefits

Member engagement can lead to a better quality of care, better health outcomes, and increased member satisfaction.

There are a number of factors which may influence member engagement:

• Understanding and trust of insurance benefits
• Belief that costs will be higher if they interact more frequently with medical professionals
• Lack of awareness about finding in-network versus out-of-network providers and the cost differences involved
• Struggle with housing stability and/or lack reliable transportation options to make it to doctor’s appointments
• Behavioral health conditions (e.g., a substance use disorder) or mental health conditions may impact a member’s capacity to utilize proper preventive or medical care services available to them

Solution:

Technology offers a more holistic view of each individual member. It can provide actionable data that tracks the member’s journey across the healthcare network. Layering other pertinent information, such as a member’s health risks, health history, demographic information, and lab work to point-of-care providers, facilitates a more proactive engagement strategy tailored to the member’s unique situation. This also helps to inform meaningful messaging and channels to use for outreach to support more equitable care by ensuring members access information about their benefits that is relevant to their needs.

Increasing member engagement in their own care, supports better outcomes and greater health equity among the member populations. Supporting members to be active in their healthcare as they engage with providers who have accurate, up-to-date clinical information can lead to improved outcomes, reduced readmissions, better quality care and satisfaction, can ultimately reduce healthcare spend.

Having the tools and processes in place to support current and future collaborative efforts as the paradigm shifts to value-based care is critical for health plan and payer organizations. They must ensure their technology platforms are set up to align with the changing healthcare landscape.