Care Management

Care management is “a comprehensive systems approach to medical care that combines the latest medical knowledge on the best clinical methods, population-based outcomes measurement and evaluation, and advanced practice tools” (Juhn, Solomon, & Pettay, 1998). From this definition, several elements of effective care management can be inferred:

• Comprehensiveness. The disease or preventive care options for a clinical condition are well characterized [Page 62]and supported by scientific evidence or, at least, consensus among experts in the disease entity. This level of understanding requires literature reviews and meetings of health care practitioners to identify best practices in diagnosis and treatment, idealized pathways of care and outcomes, and objective performance measures and indicators.
• Risk stratification. Target populations with the disease or risk factor can be identified using available data sources, including demographic information, diagnosis categories, resource utilization, costs, and epidemiological markers. The database must be sufficiently robust to provide methods of stratifying the population by some criteria, for example age, laboratory parameters, diagnosis codes, or procedure codes.
• Focus on improvement or cure. Interventions should not just focus on caring for expensive aspects of patient care; they also must concentrate resources on preventive and palliative modalities that reduce the disease burden of the population. Individuals in the population in the early stages of the disease process or who are at risk for developing the clinical condition should receive appropriate interventions, such as education or early disease detection testing kits, to help prevent or detect the disease. Patients in the intermediate or advanced stages of a clinical condition should be managed using protocols and pathways that allow customization of the care within guidelines determined by experts and literature evidence.
• Resource allocation to preventive services. Education and empowerment of individuals with a clinical problem leads to better outcomes, in general (Morgan, 1998). In addition to the improved clinical outcomes, patients often are able to reduce the cost of care through better preventive management, reducing the net cost of investments in preventive modalities.
• Continuity of care. People with chronic medical illnesses, such as AIDS or behavioral disorders, need the support of practitioners, case managers, and other health professionals to ensure that the treatment regimens are followed precisely. Frequently, a care manager assumes responsibility for these coordination and compliance processes, establishing close relationships with patients so that the rapport can translate into better clinical care and support services. Treatment and diagnostic modalities can often be uncomfortable to endure or difficult to implement in daily life, and the relationship established with a care manager can provide the impetus for an individual to comply, despite the inconvenience or discomfort. In addition, as a care manager becomes more familiar with a patient, subtle indications of changes in the patient's condition may be detected early enough to reduce complications and prevent death.
• Robust data management. Insurance data management systems and office billing systems do not usually contain enough data for care management, although they may be used for analyzing populations and identifying the target population. Clinical records from the hospital and physician's office also do not supply enough information to perform care management, because of inconsistent data recording and legibility issues. To manage care effectively and particularly to reduce the disease burden in populations at risk, a more robust source of clinical information is required. Systems such as electronic medical records, telemedicine (see entry), and Internet communications strategies make care management programs substantially more effective.

Care management companies that specialize in a specific disease entity, such as AIDS, or in behavioral health problems have advanced data management systems that record, store, and analyze clinical data in the same manner as a computerized patient record. Tracking and monitoring the appropriate parameters of an individual's health to help an individual maintain or improve his health status requires current and accurate data, and population health management requires detecting trends in health and disease burden before they become costly.

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