Providing care management to high-risk populations

Collaboration between health care teams and patients is critical to every patient’s health care journey. Without an open line of communication to discuss care management and coordination, patients may find themselves without access to necessary interventions.

At Enhabit Home Health & Hospice, team members are focused on meeting all needs of every patient, on their terms. One of the ways they accomplish this is through the Care Management Division (CMD).

What is care management?

Care management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs.

Needs are met through clinical interventions and available community resources to promote quality, cost-effective outcomes and higher rates of patient success and satisfaction.

The Enhabit care management process facilitates communication and care coordination along a continuum. Through effective transitional and complex care management, patients are able to contact the CMD by phone at any point to get advice, support or additional resources.

“When patients utilize our CMD, it really sets them up for success,” Enhabit’s Director of Care Management Kelly Guy said. “The patients that we work with are at-risk for health complications, increased emergency department visits and inpatient hospitalizations. When they can contact us for guidance and support instead of relying on the hospital, we are able to teach disease-specific education and help them improve their overall health.”

What is the goal of the Care Management Division?

The overall goal of the CMD is to improve patient care and lower health care costs.

“Our goal is to provide patients and caregivers with the tools and support they need to independently manage their health needs,” Guy said. “When we keep patients healthy at home, we also reduce the need for emergency department visits and hospitalizations. As a result, we improve our quality of care and patient outcomes all the while decreasing the costs of care and utilization of emergency resources.”

At Enhabit, the Care Management Division offers many services. These include:

• Disease-specific education and health coaching
• Symptom management techniques
• Medication review, education and side effects
• Focus on preventive care versus reactive care
• Vaccination and screening reminders
• Assistance with coordinating Medicare annual wellness visit
• Assistance with accessing community resources

Who makes up Enhabit’s Care Management Division?

Enhabit’s CMD includes collaboration between patients, caregivers, nurses, community health workers, care coordinators, providers and community agencies.

The main team members that run this collaboration include:

• Care coordinators who make the initial outreach to explain the benefits of care management to patient care teams. Additionally, they facilitate enrollment and non-emergent calls to coordinate care with the nursing staff.
• Community health workers who serve as a liaison between health care, social services and the community. They connect patients to community resources, informal counseling, social support and advocacy.
• Nurse care managers who work as case managers for a patient. They use strategies to teach self-management and develop patient-centered care plans under the RN team lead.
• RN team leads who oversee patient care plans, monitor clinical education and improve quality and efficiency with their nursing oversight.

Enhabit team members work alongside the patient’s health care teams, ensuring every patient has access to the right care, at the right time.

“A benefit of our CMD is that by using a virtual communication platform, we are able to keep in touch with both the patient and the patient’s care teams at all times,” Guy said. “This allows consistent collaboration and lowers the risk of patients having to visit the hospital to get their emergent needs met.”

The Care Management Division in action

One patient named Sheila called the Enhabit CMD by accident. She thought she was contacting her physician’s office to cancel her appointment.

Sheila needed to cancel because she didn’t have a way to get to her appointment. She was unsure how she would make it to her physician’s office without transportation.

An Enhabit nurse spoke with her about her concerns. Sheila disclosed that she was unable to afford transportation, rent, utilities or any groceries other than a jar of peanut butter. Hearing the distress in Sheila’s voice and the severity of her struggles, the nurse connected Sheila with the CMD’s community health worker.

Within a few hours, the community health worker was able to obtain two weeks of groceries for Sheila. She also enrolled her in several programs to help fund her rent, utilities and transportation to future appointments.

Without the help and intervention of Enhabit’s CMD, Sheila would have faced eviction, homelessness and starvation on top of her present health care struggles.

What are the benefits of a Care Management Division?

Increased quality of life, access to community resources, more education and a decrease in hospital and emergency department utilization are just a few benefits that Enhabit care management patients see.

In fact, 11% of patients at a Houston-based hospital accountable care organization (ACO) saw a decrease in hospital readmissions. And another 14% of patients at a Dallas-based ACO saw lower emergency department utilization after using a care management program.

The CMD doesn’t only provide benefits for patients. It also works to achieve the Quadruple Aim to lower costs for health care systems and increase provider satisfaction.

The Quadruple Aim, which is derived from the Triple Aim, is a framework created to optimize health care system performance. The framework is made up of decreasing costs, improving patient experience, enhancing population health and paying attention to the well-being of health care providers.

“Not only does our CMD help patients get access to appropriate resources for them to thrive and receive high-quality care, but it is instrumental in driving shared shavings into multiple accountable care organizations,” Guy said. “Ensuring the well-being of providers is a top priority too. The Quadruple Aim framework guides our CMD, ensuring we are always prioritizing patient’s health and satisfaction, while reducing costs for health care systems and preventing provider burnout at the same time.”

As an industry leader, we strive to provide superior, cost-effective care where patients prefer it — their homes. With a thorough understanding of each of our collaborator’s mission and core values, we help identify opportunities for impactful business growth. A collaborative partnership with Enhabit can broaden your coverage, add specialty care and expertise to your offerings, extend your care management capabilities and enhance your service distribution. 

Learn more about collaborating with Enhabit here.