CMSA Today - Issue 4, 2017 - 29

1. Patients value providers that respect and
value them in return.
2. Patients want the relationship with their
providers to be convenient for them,
and they want information that is useful in understanding and managing their
health or their condition.
3. Patients want a convenient, easy-to-use
and easy-to-access system that connects them to their providers and keeps
patients themselves at the center of their
own care.
WHICH PATIENTS SHOULD BE
ENGAGED, AND HOW?
Before patients can be engaged, it's
important to identify and target the right
patients for an engagement strategy. We
know that the prevalence of chronic disease climbs as the population ages beyond
55 years, and that utilization and hospitalization rates climb in tandem after age
55.6 Additionally, as many as 65 percent of
Medicare beneficiaries have multiple chronic
conditions7 including heart failure, chronic
obstructive pulmonary disease (COPD), and
diabetes. Patients with these chronic diseases typically account for twice (or more)
the cost of care for an average beneficiary,
and these same individuals experience three
to four times as many hospitalizations a
year.8 Targeting the right patients to become
involved in their own self-care goes far in
keeping those same patients healthier-and
it's the first step in a patient engagement
strategy. But how do you do that?
Finding the right patient engagement
tools and platform can help. Whether
patients have come under your care posthospitalization or because they are managing a chronic illness, there are three key areas
that an effective patient engagement tool
should measure:
* Clinical status (vital signs, current
symptoms)
* Self-care status (doctor appointments
kept, medication adherence, eating
nutritious foods, and other activities of
daily living)
* Social determinants of health (social isolation, affordability and access to care,
transportation issues, living environment)
A clear view into a patient's clinical and
self-care status, as well as important insight
into their social determinants of health gives
a care manager a more comprehensive view
into what is going on with that patient.

Have they gained a significant amount of
weight in the past few days? Is that due to
eating the wrong foods, or are they retaining fluid? Are they keeping their doctor's
appointments? If not, is it due to a lack
of transportation?
Taking care of patients and getting them
to a place of self-management is more
than monitoring their clinical symptoms
and status. It requires a holistic understanding of how a patient lives. Everything
from a patient's dwelling, neighborhood,
socio-economic status, and access to technology informs how we care for patients-
and how well they can follow a care plan
for themselves.
A PATIENT ENGAGEMENT
STRATEGY: THE PROCESS,
PEOPLE AND TECHNOLOGY
An efficient way to manage care for risingto-high-risk patients begins with a patient
engagement program that brings together
people, process and technology. One clinically tested program that has reduced readmission rates in multiple health systems and
accountable care organization consists of
five components:
1. Patient identification
2. Enrollment activities
3. Daily health status monitoring
4. Patient retention support
5. Outcomes reporting
PATIENT IDENTIFICATION
(PROCESS)
Organizations begin by identifying the
best candidates for the engagement program. Patients are identified using daily transition/discharge lists, claims data, attributed
beneficiaries, or diagnosis code methodologies. Finding those patients who are at risk
as they use the healthcare system allows care
managers to initiate education and interventions early in their healthcare visits.
ENROLLMENT ACTIVITIES (PEOPLE)
A team of engagement specialists markets the program to prospective patients.
Mailing campaigns, brochures, call center
campaigns and in-person conversations
between providers and their patients help
patients understand the value and benefits
of engagement, educating them on why participation in such a program will help keep
them on track. Patients are engaged in the
program in a way that is most convenient to

them whether they participate over the phone,
online, or through a mobile app.
DAILY HEALTH STATUS
MONITORING (TECHNOLOGY)
Patients check in with their providers by
completing a daily health survey via phone or
Internet connection. Patients answer a short
series of questions about their clinical status,
self-care activities, and social determinants of
health. Clinical algorithms detect subtle shifts in
a patient's self-reported data and, when necessary, trigger alerts to care managers for further
follow-up with the patient. In this way, care
managers can work directly with a prioritized list
of patients who need attention at the time they
need it. This replaces the need for traditional
programs that focus on blind calls, by removing
the guesswork. The system is designed to get
patients the right level of care at the right time.
PATIENT RETENTION
SUPPORT (PEOPLE)
The team of engagement specialists continually reviews patient engagement activity,
flagging and contacting those patients who
need an extra boost to stay proactive with the
program. It also contacts successful patients,
praising and encouraging them to continue
their path to better health.
OUTCOMES REPORTING (TECHNOLOGY)
Continual analysis of learnings from enrollment and retention activities, along with daily
engagement of patients, optimizes the programs to get additional qualified patients identified and participating.
CARE MANAGERS: THE ESSENTIAL
INGREDIENT OF ENGAGEMENT
The best patient engagement programs
are intuitive, straightforward, and easy to use.
They leverage technology but retain the caring,
human touch of caregivers and care managers-an incredibly important distinction. Apps
and technology on their own don't provide
the "engagement" component necessary
for success.
Let's take a closer look at a patient engagement program and how the care management
team makes it work. Patients provide information via a daily survey that includes their
vital signs, their self-care status and information related to social determinants of health.
Patients can take the survey via telephone,
computer or smartphone-the choice is theirs.
They use the technology most comfortable
Issue 4 * 2017

CMSA TODAY

29



Table of Contents for the Digital Edition of CMSA Today - Issue 4, 2017

President’s Letter
Association News
CMSA Conference Supporters
CMSA Corporate Partners
Case Management at the Helm of Diverse America
Community Health Workers: A Key Role on the Collaborative Care Team
Ticket to Work: Strategies for Case Managers Who Face Work-Disrupting Disabilities
For Case Managers, Success Requires Mastering Today’s Challenges
Using a Patient Engagement Strategy to Help Care Managers Educate Patients at the Right Time—Before It’s Too Late
Index of Advertisers
CMSA Today - Issue 4, 2017 - Intro
CMSA Today - Issue 4, 2017 - cover1
CMSA Today - Issue 4, 2017 - cover2
CMSA Today - Issue 4, 2017 - 3
CMSA Today - Issue 4, 2017 - 4
CMSA Today - Issue 4, 2017 - 5
CMSA Today - Issue 4, 2017 - President’s Letter
CMSA Today - Issue 4, 2017 - 7
CMSA Today - Issue 4, 2017 - Association News
CMSA Today - Issue 4, 2017 - 9
CMSA Today - Issue 4, 2017 - CMSA Conference Supporters
CMSA Today - Issue 4, 2017 - CMSA Corporate Partners
CMSA Today - Issue 4, 2017 - Case Management at the Helm of Diverse America
CMSA Today - Issue 4, 2017 - 13
CMSA Today - Issue 4, 2017 - 14
CMSA Today - Issue 4, 2017 - 15
CMSA Today - Issue 4, 2017 - Community Health Workers: A Key Role on the Collaborative Care Team
CMSA Today - Issue 4, 2017 - 17
CMSA Today - Issue 4, 2017 - 18
CMSA Today - Issue 4, 2017 - 19
CMSA Today - Issue 4, 2017 - Ticket to Work: Strategies for Case Managers Who Face Work-Disrupting Disabilities
CMSA Today - Issue 4, 2017 - 21
CMSA Today - Issue 4, 2017 - 22
CMSA Today - Issue 4, 2017 - 23
CMSA Today - Issue 4, 2017 - 24
CMSA Today - Issue 4, 2017 - For Case Managers, Success Requires Mastering Today’s Challenges
CMSA Today - Issue 4, 2017 - 26
CMSA Today - Issue 4, 2017 - 27
CMSA Today - Issue 4, 2017 - Using a Patient Engagement Strategy to Help Care Managers Educate Patients at the Right Time—Before It’s Too Late
CMSA Today - Issue 4, 2017 - 29
CMSA Today - Issue 4, 2017 - Index of Advertisers
CMSA Today - Issue 4, 2017 - cover3
CMSA Today - Issue 4, 2017 - cover4
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