Aligning resources to needs for population-based chronic care management

According to the Centers for Disease Control and Prevention (CDC), approximately 6 in 10 adults in the United States have at least one chronic condition (such as heart disease, diabetes, arthritis, etc.), and 4 in 10 adults have two or more chronic conditions. 90% of overall healthcare spend can be attributed to people with one or more chronic medical conditions. Effective management of chronic conditions can help to improve health outcomes and reduce healthcare costs.

The top 5% of people accounted for 50% of total healthcare spending in most health plans. That's why traditionally care management teams have focused on the highest-risk members. However, there is significant evidence to support that confining your care management efforts to the highest-risk segment of the population does not lead to effective cost reduction at the aggregate level. Various research studies have shown that approximately 30% of members move out of the very complex risk band (0.5% of the population) within one month; 50% after five months and 80% after one year. Thus risk stratification results based on past data quickly become outdated. Also, often this cohort is very well known to primary care and their care management is already optimized in many cases. Risk stratifying deeper into your population allows for preventing more emergency admissions not just because there will be more people but also because people at relatively lower risk scores present greater opportunities for health outcomes and cost optimization.

Interventions such as preventive & primary care, care coordination, chronic disease management, and addressing social drivers of health are effective tools to manage chronic conditions. However, providing these services to a large subset of the member population can be cost-prohibitive.

The pyramid of care model can be a valuable framework for managing individual members with chronic conditions, as it helps to ensure that members receive appropriate care that is tailored to their specific needs, while also promoting the efficient use of healthcare resources and improving outcomes. By utilizing this framework, healthcare plans and providers can ensure that members receive appropriate care at the right level of the pyramid, while also optimizing the use of healthcare resources.

The pyramid of care model consists of three levels, each with increasing levels of complexity and resource intensity:

Level 1: Supported Self-management - This level involves providing members with the knowledge, skills, and resources they need to manage their health, such as education on healthy lifestyle habits and how to monitor and manage their symptoms. This level also involves the provision of routine care by a primary care provider, such as regular check-ups and medication management.

Level 2: Complex care management (CCM) - This level includes ongoing chronic care coordination and interventions for episodic, temporary needs, to regain optimum health or improved functional capability in the right setting and in a cost-effective manner. Complex care management requires coordination of care between a range of healthcare professionals, such as primary care, condition-specific specialists, and community health workers, to provide more integrated care to members with more complex needs.

Level 3: Enhanced care management (ECM) - This level involves the provision of clinical and non-clinical needs of the highest-need members through intensive coordination of health and health-related services. ECM is community-based, interdisciplinary, high touch, person-centered, and provided primarily through in-person interactions.

The pyramid of care model emphasizes the importance of providing members with the right level of care at the right time, based on their level of need. By providing members with appropriate levels of care, health plans, and care providers can improve health outcomes, reduce healthcare costs, and promote member satisfaction with their care.

Connect with us?to learn about how our whole-person care platform provides the technology infrastructure to implement data-driven population health management by leveraging the pyramid of care model, and achieve better and more equitable outcomes for all of your members, no matter where they are on the spectrum of need.