Explore frequently asked questions related to Care Management.

In practice, “care management” and “case management” often refer to very similar functions, and many organizations use the terms interchangeably​. Both involve coordinating care for patients with significant health needs through assessment, planning, and facilitation of services. If a distinction is made, case management sometimes refers more specifically to managing individual “cases” – for example, focusing on a patient with a catastrophic injury or a complex hospital discharge – whereas care management can imply a broader, ongoing management of a population of patients (often those with chronic illnesses) to keep them healthy. However, the core goal in both is the same: coordinate care to improve quality and outcomes while controlling costs.

Disease management refers to programs that are focused on a specific chronic disease or condition, whereas care management is broader and more holistic. In a disease management program, the goal is to improve outcomes for that one disease across all patients who have it – for example, a diabetes management program might give all diabetic patients educational materials, regular nurse check-ins about blood sugar control, and reminders for eye exams. It’s often protocol-driven and condition-specific. Care management, on the other hand, looks at the whole patient. A care manager will address all the issues a patient has – if that same diabetic patient also has heart disease and depression and social needs (like transportation challenges), the care manager coordinates care for all of those, not just diabetes. You can think of disease management as one piece of the puzzle (focused on a single illness), whereas care management is the whole puzzle, coordinating multiple aspects of a patient’s health.

A Plan of Care, or care plan, is a written roadmap for a patient’s care. It’s an individualized document that outlines the patient’s health conditions, sets specific goals (such as improving blood pressure or mobility), and lists the actions/interventions needed to reach those goals​. For example, a care plan for a patient with heart failure might include goals like “reduce hospitalizations” with interventions such as daily weight monitoring, a low-sodium diet, medication management, and scheduled nurse check-ins. A care plan is created collaboratively – often the care manager develops it together with the patient (and sometimes their family and doctors) so that the patient’s personal preferences and life circumstances are taken into account​. Importantly, the care plan is a “living document”: it is shared with the whole care team and updated regularly as the patient’s situation or goals change. By having a clear plan of care, everyone involved knows what the patient is working towards and what each person’s role is in supporting the patient’s health.

Risk stratification is the process of categorizing patients based on their health risks. In care management, this typically means using data – such as medical history, diagnoses, lab results, or claims – to identify which patients are at higher risk of experiencing serious health issues or high healthcare costs. Patients might be grouped into tiers like low-risk, rising-risk, and high-risk. This helps care management programs target their resources: for instance, high-risk patients (like those with multiple chronic conditions or recent hospitalizations) would get more intensive care management, whereas low-risk patients might just get preventive care reminders. In short, risk stratification allows care managers to focus on the patients who need the most help first.

Care management usually follows a step-by-step workflow to ensure each patient gets comprehensive support. The main steps include: (1) Identification: finding or enrolling patients who would benefit (often through risk stratification or referrals). (2) Assessment: the care manager conducts a thorough assessment of the patient’s health status, medical history, medications, and social factors. (3) Care Planning: based on the assessment, a personalized care plan is created with the patient, outlining goals and interventions. (4) Implementation/Coordination: the care manager coordinates the services and resources in the care plan – for example, arranging specialist appointments, connecting the patient to a nutritionist or a support group, and ensuring providers are all on the same page. (5) Monitoring and Evaluation: the care manager regularly checks in on the patient’s progress (monitoring health indicators, following up after doctor visits, etc.) and evaluates whether the care plan is working. They will adjust the plan as needed – if something isn’t helping or a new problem arises, the plan is updated.

NCQA stands for the National Committee for Quality Assurance – it’s a U.S. non-profit organization that develops quality standards for healthcare and accredits programs like health plans, medical homes, and case management programs. NCQA is highly relevant to care management because it offers a Case Management Accreditation (among other accreditations) that sets the benchmark for what a good care management program should entail. Organizations (including health plans, TPAs, and care management service companies) seek NCQA accreditation to demonstrate that their care management processes meet national best practices. NCQA’s standards ensure that a care management program has all the key elements: for example, systematic methods for patient identification and assessment, proper care planning, ongoing care monitoring, and effective care coordination across services

Yes, the journey can be customized to include referrals to dietitians if they are available under the member's plan.

Yes, links to external resources can be embedded within the text of the messages sent to members, making it easy for them to access additional information or services such as a provider finder.

Yes, digital health journeys can be embedded into existing member portals via Single Sign-On (SSO), making the experience seamless for members without additional login requirements.

We support a multi-pronged approach to the member experience, ensuring we meet customers' integration requirements.

Medecision’s member app can be delivered as a standalone, browser-based experience, eliminating the need for native app downloads;

• Medecision’s member app can be embedded via single-sign on (SSO)\ • We could also support a deep API level integration where you customize the experience.

Yes, the member browser-based experience is mobile responsive.

We can support the development of custom native mobile apps if there becomes a market or business need to do so.

Yes, assessments and surveys are highly customizable. You can customize content, frequency and the triggers that generate the assessments or next best actions.

Yes, behavioral health questions can be included in the digital surveys and assessments, and they can be customized based on your specific needs and requirements.

No, there is no limit to the number of questions that can be included in a survey or assessment, and you can nest as many questions as needed.

The system provides an intuitive assessment builder that allows you to create and edit assessment templates easily.

Custom fields and reminders can be set up, including mandatory questions that need to be answered before a program can be closed, ensuring compliance with NCQA requirements.

Yes, the system can automatically send reminders and nudges to members who haven't completed their assigned tasks, such as surveys, educational content, or periodic check-ins. When you create the journey in Journey Builder, you can set up automated reminders to prompt members to take action within a specified timeframe. For instance, you can configure the system to send an initial reminder if a member hasn't completed a survey within 2 days. If the task remains incomplete, a second reminder can be sent the following day. As a last resort, a notification can be triggered to inform the clinician of the pending task, ensuring timely follow-up. This automated process helps enhance member engagement and ensures critical tasks are completed promptly.

Yes, Population Builder allows you to precisely define specific groups of members for whom the journey is tailored. When creating these populations, you can apply a variety of filters such as demographics, clinical history, claims data, and more to segment your audience accurately. Additionally, custom fields can be built to further refine your targeting. This functionality ensures that interactions are highly personalized and can be turned on or off for specific groups as needed, enhancing the relevance and effectiveness of the engagement.

Yes, our scheduling feature can route appointment requests based on state licensure

Yes, both pre-set and custom educational content can be sent to members through the platform. Clinicians can send educational materials based on assessments or manually as needed.

Yes, the system tracks all member interactions with the educational content, including timestamps for when the content was accessed.

The platform includes a medication reconciliation feature that starts with claims data, allowing clinicians to edit, add, or discontinue medications as required. This is part of the new UI/UX and is available without additional charge.

Yes, the medecision supports the ability to test customized journeys before moving them to production. This ensures that you can see how the customization runs and verify that it behaves as expected before making it live in the product environment.

Care Management Enterprise with Co-Pilot enhances our guided health journey capabilities, utilizes assistive displays such as case summaries and suggested next best actions automating many manual tasks traditionally completed 100% by care/case managers. Our AI Agent builder allows customers to create new and targeted AI capabilities.

medecision leverages advanced automated workflow, enhancing the efficiency and effectiveness of care management. As it relates to case management, medecision utilizes predictive analytics to identify high-risk members who may benefit from proactive intervention or care management programs. By analyzing historical data and risk factors, our predictive models can forecast the likelihood of events such as ER visits and hospitalizations, providing care managers with prospective views into future costs and enabling targeted interventions.

Our system supports a sophisticated alerting framework designed to effectively communicate a range of information criticality and action requirements to all stakeholders involved in patient care. Alerts can be included at various levels of the platform starting with the patient level including clinical indicators, user driven alerts and third-party alerts ingested through the data platform. This ensures that every team member has immediate access to essential information, facilitating prompt action and coordination for the patient's most urgent needs. Additionally, the system generates actionable alerts transformed directly into tasks within the workflow, guaranteeing that critical insights lead to swift, appropriate responses. The care management system is designed as a task driven platform ensuring the right alerts and actions are delivered to the right team member through data driven automation.

Moreover, the system includes informational notification-type alerts to enhance situational awareness among care team members. These notifications can be escalated to tasks if further action is deemed necessary, providing flexibility in managing various levels of alert severity. Customizability is a key aspect of our alerting system; it is designed to be tailored to fit the specific clinical workflows of our customers while integrating Medecision’s recommended best practices. This ensures an optimal balance between meeting unique organizational needs and adhering to industry-leading care management standards.

As a part of medecision's care management workflow, you can identify at-risk members through standardized assessments. We enhance the screening process with pre-defined assessment templates that fully comply with CMS Health Risk Assessment (HRA) requirements. These templates provide a structured and efficient approach to evaluating social determinants of health, allowing your teams to quickly pinpoint and address member specific needs.

medecision's pre-built assessments go beyond identification by incorporating next-best actions, which automatically trigger the appropriate alerts when needs are detected. You can leverage these ready-to-use assessments as they are or customize them to align with your unique care management strategies.

Yes, Medecision's platform provides pre-existing Care Plans that streamline care management processes. These plans outline key elements such as problems, goals, barriers, and interventions, offering a structured approach to member care.

• Automatic Problem Generation from Assessments: medecision's intelligent capabilities automatically analyze assessment responses and generate relevant problems. These problems are then associated with appropriate goals and interventions, further streamlining the care planning process.\ • Pre-built Problems with Goals and Interventions: Our library includes pre-built problems with associated goals and interventions, providing a convenient starting point for care teams. You can choose to utilize these pre-built elements or customize them to fit the specific needs of your members.\ • Plan of Care Customization: medecision's Plan of Care module empowers care teams to build and customize personalized plans for each member. This flexibility allows you to tailor interventions to address individual member circumstances and optimize outcomes.

medecision supports over 300 activity trackers, wearables, and fitness apps. Once the member authorized to share data the platform leverages real time analytics to automatically sync data to identify opportunities for personalized care management programs and outreach.

Yes, Medecision’s solution fully supports client clinical code sets, ensuring seamless integration with payer clinical systems. The platform is designed to accept, normalize, and standardize data from multiple sources, including various clinical code sets used in healthcare. Through scalable, API-driven integrations, the solution enables efficient data exchange and interoperability, allowing payers to leverage existing clinical coding frameworks within our care management platform. This capability enhances data consistency, accuracy, and communication across healthcare ecosystems.

medecision's built-in clinical intellgence engine offers robust capabilities to identify high-cost, high-value, and high-utilization clinical target members and populations to enable your teams to focus their engagement efforts on those who would benefit most from targeted interventions:

• Integrated Clinical Data: medecision Data & Intelligence Platform (ADP) integrates clinical data from multiple sources, including Electronic Health Records (EHRs), claims data, and pharmacy records, to create a comprehensive view of member health status, utilization patterns, and cost drivers. An example includes identifying frequent visitors to EDs through real time ADTs and the ability to outreach at discharge to connect with a care manager\ • Advanced Analytics: ADP utilizes machine learning algorithms to identify members with high healthcare utilization, and potential for cost reduction or improved health outcomes. These models also include predicitive components around likelihood of hospitalization and likelihood of ED visits that be avoided through early and timely interventions\ • Risk Stratification and Segmentation: ADP performs risk stratification and segmentation to group members based on their clinical characteristics, utilization patterns, and predicted costs. This enables the identification of high-risk, high-cost, and high-value populations for targeted interventions.\ • Predictive Analytics: ADP employs predictive analytics models to identify members at risk of future adverse events, such as hospital admissions, ED visits, and chronic disease complications. This allows your teams to proactively intervene and prevent potential complications, reducing healthcare costs and improving member health outcomes.\ • Cost-of-Care: ADP generates cost-of-care views for individual members and populations, enabling your teams to identify those with the highest potential cost burden and prioritize interventions to reduce costs and improve efficiency.

The system can be configured to meet specific requirements for integration with print management systems through the following features:

• Document identification: Supports identification of specific documents that should be included for the Print Management System.\ • Scheduled delivery: Supports the creation of schedules for documents to be delivered to the Print Management System.\ • Grouping and Sorting Logic for Letters: Supports the specification of the format for outputted documents that are delivered to the Print Management System.\ • Address Formatting: Supports the particular letter addressing format required for the Print Management System.