Patient care is part science (i.e. tests, treatment) and part art (i.e. communication, motivation, prioritization). Today, effective population health solutions can link the science and the art in a game-changing way that will help care managers deliver better care, more efficiently.

Care managers are asked to do a lot. The typical care manager at a large hospital network has a full case load, which limits the ability to deliver quality care across a population. The reality is that we’re not going to have enough care managers to care for the growing number of patients, so we have to become more efficient. We also need to empower motivated patients to manage their own care.

Caradigm® Care Management was developed in partnership with Geisinger Health Plan based on extensive observations of their care management team. Together, we came to the conclusion that what care managers needed most was to 1) have complete data and analytics in a single workspace and embedded into workflows and 2) automate routine processes. Here are just a few examples of how a care manager’s life can be made easier:

• Task lists and interventions are automatically generated from assessment responses that list the top interventions needed to get the highest risk patients to a better place and assure consistent work practice.
• Complete medication histories can be brought into single patient views that display order history and fill history for easy review.
• High risk patients can be tracked across the continuum through event-based alerts (e.g. admissions, discharges or blue tooth device alerts).
• With a full 360 degree view of patients, care managers can see longitudinal data and patient responses over time, identify and address subtle changes and deliver patient centered care by incorporating patient personalized goals into care plans.
• Patient workloads or specific tasks can be reallocated to other care managers or support staff, assuring “top of license” activity.
• Best practices of care managers can be identified and then shared across the team.

This is exciting, transformational change. Care managers today are hunting down information from many systems and storing that information all over the place on sticky notes, notebooks, applications, and then must synthesize that into a care plan. Multiply that by 50, by 100, by 200 patients, and it’s challenging to do it efficiently. Caradigm’s population health management solutions are transforming care management, and I am thrilled to be part of the journey.