Innovating Care Management through Operational Excellence Delivering Value

Care management is crucial for adding value to value-based care, but gaining stakeholder buy-in on its significance can be challenging. While the return on investment for care management strategies is undeniable, the delayed realization of these returns can be daunting for financial leaders. In this episode of Value-Based Care Insights, Dan Marino sits down with Lisa Stockdale, the Director of Value Based Care, at Silver Cross Hospital, to look at challenges, as well as the benefits, in implementing successful care management programs. Gain insights into the importance of leadership buy-in, technology, and reinvestment in effective and cost-saving care management programs.

LISTEN TO THE EPISODE:

 

Daniel Marino:

 Welcome to value based care insights. I'm your host, Daniel Marino. When you think about value-based care, and in particular the performance of value-based contracts. Care management is absolutely essential to realizing any type of performance outcomes and really identifying the value that that we need to provide to our patients and frankly providing the support to our, to our physicians and our providers. Yet many organizations, many CINs, clinically integrate networks or ACOs, or just health systems, who are starting to engage in value based contracts. They really struggle with how to efficiently perform care management services, or to even invest in care management services. I can remember having conversations, even, you know couple of years back with CFOs relating to investing in care management. And it was tough, because care management doesn't provide that immediate ROI. Yet it is absolutely essential to realizing the results of any type of value based contracts.

Well, I'm really excited today to have as my guest Lisa Stockdale. Lisa is director of value, based care at Silver Cross Hospital. She has been in the care management world and has been instrumental in working with her physicians, her providers, her patients and her team in putting in place really effective care management programs. And frankly, the organization that she works for has really has realized some, some real nice shared savings and financial opportunities there. And it's a direct result of the care management that Lisa has put in place in her team. Lisa, welcome to the program.

 

Lisa Stockdale: Thank you, Dan. Happy to be here today.

 

Daniel Marino: So I know the work that you've done in care management has certainly not come without a lot of bruises and overcoming a lot of challenges when you think about what you've been able to put in place. And then you think about what other organizations struggle with, what are some of the biggest challenges related to implementing care management or putting in place an effective care management program?

 

Lisa Stockdale: Well, the 1st thing that we really had to tackle was getting like you mentioned finance to agree to invest in this program. So when we met our vendor we started working together in the fall of 2,019. So it was an 18 month project of really creating the storyboard for the leadership team here at our system to help them understand what the potential impact of a program like this would be. So we really approach the finance team, utilizing the study from Mathematica on care management, which was a very small cohort of population of patients. And looking at what our total spend and total cost of care was in our Medicare shared savings program, and forecasting what we might be able to save if we were to implement an effective care management program here. So that's really what got us over the hurdle. The way we look at the reimbursement for CCM, is it sort of keeps the lights on but the the shared savings and the impact to quality that we've seen is just a testament of the team. But that was really the 1st hurdle that we had to get over was changing the approach of, you know, care management. We're not just doing this for reimbursement. We're actually doing a community benefit with the reimbursement.

 

Daniel Marino: When you're investing in, you're investing in your teams, right? And you're investing in the future. You know the big challenge with any of these value-based care contracts is you may not see or receive the performance dollars until you know a best case is probably 14 or 15 months after you sign the contract. In some cases it's even longer than that. So you know, that's hard to build that into an ROI model. But it's absolutely essential in order for you to achieve those results. So when you, when you had worked with finance, I would assume really changing that mindset with your leadership, I mean, that had to be the biggest undertaking.

 

Lisa Stockdale: I would say, yes, I think you know, the culture of the organization you're in makes a big difference, and I'm very honored that that our culture here is built on quality, so that part was easy to get through right. Because the quality is there. So it was just really selling the potential opportunity. And you commented on investing in your team. I am just honestly so proud that we now have a way for clinicians to work remotely and care for patients. It's given us another vehicle, another opportunity to attract top talent in our market. Because the positions are attractive. And we have had 0 turnover in 3 years since we launched our program. So that's we're growing. We're hiring. My staff is referring friends and colleagues. So that just speaks volumes to me. About the program and their satisfaction at their job as well.

 

Daniel Marino: When you, when you think about the operations of your team. any, any strong care management program is really multi faceted. Right? So I mean, I'm assuming you have probably nurses who are managing the high risk population versus those that are moderate risk, and even doing navigation right? Patient navigation. Can you speak a little bit around say the operational effectiveness of your team, and maybe how you've structured it?

 

Lisa Stockdale: Sure. And I think that's a big, you know, testament to the partner that we have the technology really allows us to scale low cost, high value resources. So we do have pay medical assistance that have panels. They're supervised by RNs. So we do have sort of the day to day tasks that are occurring. And, like you, said, the navigation pieces are handled by a medical assistant, and then clinical escalation, or those higher risk, sicker patients can be managed by the RN. So it's really afforded us an opportunity to manage more patients and work with them, as they're sort of going through their care journey. There are points in their life where they need more support than others. So having that team based approach, and that, you know they're tethered to the physician or to the app, the advanced practice providers. It just has given the patient such a significant support system, and we've invited them to their care, and just seen tremendous results from that.

 

Daniel Marino: Well, you're really coming at this like you said from a team based perspective. So you have different levels of, let's say, clinical capability that you're bringing to the table to support, not just the clinician, as you mentioned, but to but to the patient as well. So care management obviously is expensive. In some cases there's been care management incentives that are part of the contract. I know Medicare has done that in the past. But one of the things that I'm particularly excited about was CMS released their new proposed reimbursement for advanced primary care management services, and for any of our audience members. If you're not aware of it, we'll include the link in in our notes. But it provides for a lot more codes around care management, and they've changed the rules a little bit in terms of how to better support the actual care management activities that's occurring between the clinician, between the patient and allowing more proper reimbursement for that. In your experience, Lisa, and I know you're just starting to get into this. What's your thoughts on the new releases from CMS?

 

Lisa Stockdale: I mean excited honestly. Nervous a little too, cause we have to figure out how to operationalize that.

 

Daniel Marino: Yeah.

 

Lisa Stockdale: But you know this is CMS’s gift, I would say to providers, and recognizing that these programs actually do deliver on an overall improved outcome for the patient, for the consumer and for all of us. Right? Because we're paying taxes to fund Medicare. So I take high responsibility for that in in our program. But APCM is really actually going to personalize the care management even further because not every patient needs 20 min every month. And so what happens is we deliver care 5, 7 min, 6 min here and there, and we're not able to actualize our reimbursement for that care. So with these new programs while they have a little bit of a lower reimbursement rate, we don't won't have to really drive that 20 min threshold if it's not necessary. So that's really exciting for me as I feel the patients are going to get a more personalized approach to their care management. And as far as the APCM program with the 3rd code that's released, kudos to CMS, there is higher levels of reimbursement or are qualified Medicare beneficiaries that are on the Medicare and Medicaid alignment programs, where we already know they have a financial social factor influencing the ability to manage their health. There's not going to be any concerns with patient cost sharing. And there's going to be higher reimbursement for the caregivers due to the fact that these folks have, you know, much further support needs than some of our other patients. So really, just aligning the reimbursement with the need of the patient population is really what I feel is very exciting to see coming from CMS.

 

Daniel Marino: Yeah, I agree with you. I'm excited for this, I think for a couple of reasons. One as you mentioned. You're really focusing the care management based on the patient's needs. Right? So the criteria obviously is important documentation always becomes important. But in care management we're really focused on the outcomes. Right? We're really focused on delivering the right level of care, the right level of service with the idea that we're advancing hopefully the quality and the outcomes of that patient to make them better, or whatever the case may be. I feel like the code set that CMS has come off come out with is really going to help. You're never going to get rich off care management, but you shouldn't be losing a lot of money either, and I think if this allows us to better align our financial elements with what is occurring within, for you know the needs of care management. I think that's absolutely key.

 

Lisa Stockdale: Yeah. And you make a great point there. Again, we talk about the reimbursement keeping the lights on and we're very conscientious with how we manage that. We know the labor is, you know, our largest cost factor. We're still realizing a profit of about $200 per patient per year in CCM. And what we've been able to do is reinvest that back into our primary care, clinics for additional support services. So just even a further way that we've been able to give back to the groups there. But sort of the icing on the cake is we are in the process of conducting a retrospective claims analysis for the patient population that we have enrolled in CCM. Versus our non-enrolled patients through our Medicare shared savings program, and we are starting to see, and we sliced our data 3 times 4 times to stress test it. And on average, we're generating approximately $1400 per patient per year in those risk, aligned populations. So we're comparing similar risk scores to similar risk scores and looking to see what we're finding massive changes in utilization patterns around part a utilization swinging back into the primary care setting, which is just really exciting. So another value add to the PCP is our patients are on average, seeing them 2 additional times per year, where that patient might have been delaying care and having that be more of a an acute condition, or they're selecting urgent care, or they're seeing their specialists when it's really something their primary care physician can handle. So building that tighter bond with the PCP and the patient has really also been just a phenomenal out, you know, improvement that we've see with the program as well.

 

Daniel Marino: If you're just tuning in, I'm Daniel Marino, and you're listening to value based care insights. I am here talking to Lisa Stockdale, and we're talking about innovations of care management, responding to a lot of the recent CMS changes and so forth. So the, I love your numbers, Lisa. I love the fact that you're you know you're identifying what the financial opportunities has been have been through integrating care management. You know you mentioned the $200 per patient per year as a as a net income. And then some of the other investment things that you've been able to do. What have been some of the maybe, if you can give us a few examples, what have been some of the concrete, let's say, operational challenges, using your data, that has been a bit of a game changer for you and for your team?

 

Lisa Stockdale: Really, we're teaching medical assistance how to care, manage, and proactively. Go find patients that are in need. I think, because the system itself is built in that reactionary model that it's a little foreign for staff to go nudge a patient, ask them something, trigger them the patient to respond to you. So we've spent a ton of time working with our employees and our care managers to, you know, really, redefine that experience for the patient and service the patient almost like a concierge type of program. So.

 

Daniel Marino: Yeah. And that's boy. That's a great point. Because I'll tell you. So many of us and healthcare for years have reacted to what's occurring with the patient. Right? So if a patient, and we know that ourselves, if we don't feel well, or if there's something going on, we we're not proactively, even in our own care of working with our providers, we react to something. And then, as physicians and as clinicians for the most part, you're reacting to what's occurring with the patient. So just the fact that you're using the data and changing that educational mindset with your MAs to start thinking about it a little bit more proactive, getting out in front of that absolutely the key, and being able to drive those results.

 

Lisa Stockdale: I agree with you. And I would say the last, you know, example really is the care planning process. And you know the beautiful thing about teamwork and healthcare is, you don't have to think of everything yourself, and you shouldn't. When you give clinicians tools they will go above and beyond your wildest imagination. Our nursing team got together and completely reconstructed our care planning process and put definitions around it. It's a Quarterly review, a Biannual update. It's a living, breathing document. The patient is shared. Their care plan through their text links on their phone as they participate with us. So as their care journey is changing their care, plan lives and breathes with them. And that is where we are also screening our patients for social determinants of health.

 

Daniel Marino: Oh!

 

Lisa Stockdale: I am so proud that they have tackled that

 

Daniel Marino: Absolutely.

 

Lisa Stockdale: Yes, and really, just being able to ask patients about, you know, do you feel safe in your home? Can you afford your lights and water and your food? And using those evidence-based screening questions. When we find those issues, those are notes going right to the physician or to the app saying, we've identified this. And then the, you know, sort of chain reaction occurs. The beauty of care management that 20 min can really be spent on whatever the patient needs at the time. So our team is now building relationships with our community based partners. We've been running a food bank program since 2021.

 

Daniel Marino: Oh, so socioeconomic and other health equity issues have really come into play. It sounds like within your care management approach.

 

Lisa Stockdale: Yes, and I believe that's 1 of the things that's impacting, you know the total cost of care performance where patients were not taking meds because they couldn't afford them, and things like that. So that that's really just been a beautiful thing to see unfold. And the clinical team has just taken that on and embedded it in our care planning process. And so that's really where we've seen successes with that.

 

Daniel Marino: How impactful or important has the technology support been to your care management team? I know you're doing a lot with data and you're really trying to understand from an analytic standpoint, what's occurring with your patients and your population. But how about the technology? How's that come into play?

 

Lisa Stockdale: Our program wouldn't be possible without our partner. And there's a couple of reasons why. The program is run off an SMS texting platform. Which step one. There is no barrier unless you can't text and there are those cases where folks don't have phones that text. But there's no apps to download. On the flip side the enhancements and the automation and scale that it gives to the clinical team is something I've never seen from another partner, another vendor being able to have an MA, you know, sort of run the day to day operations of that 500 patients and checking in regularly with folks, that that's really what's drove the majority of the ROI, because we are able to handle a lot more patients yeah, without adding additional labor.

 

Daniel Marino: Well, and I'll tell you it's the old adage, right? People processing technology.

 

Lisa Stockdale: Exactly.

 

Daniel Marino: Strong technology platform in order to support the care management that you want to deliver. You can only do so much. I mean, I could imagine your panel per care management, professional you know, and this probably varies depending upon risk level. But it's probably pretty high, and my guess is the only way that your staff is able to efficiently get through that and provide the care that they need is because you've got strong technology support behind you.

 

Lisa Stockdale: Yeah, it's exciting. We just crossed over the 3,000 mark plan for expansion for the rest of the year, just seeing the results that we're getting the organization is very excited to grow the providers are on board. So it's definitely been a good partnership, and, like I said, couldn't do that without a good partner, because EMRs are not set up like this. There's not many population health technologies out there that can accomplish something like this. So it's great for the patients, and also great for the clinician. And that's you know, where I see the sweet spot with the with the partners we have.

 

Daniel Marino: Well, and you have to have, as you said, you've got to have a strong care team that can work together, be able to and have it multifaceted from our ends all the way down to those that are handing patient navigation. But the technology is absolutely key. So one question that I do have, and maybe this focuses a little bit more on your growth. So I've been impressed with where CMS is going. They're certainly taking the lead in a lot of the care management work, and providing some incentives and support for those that are really, you know, around the Medicare patients if you will, but the commercials, it seems like to me, have been a little slower to react. Not necessarily providing the right level of financial incentives or care management support to organizations, to manage the commercial population. Is that true? What are you seeing around that that level of payer support?

 

Lisa Stockdale: 100% agree. I think the challenge for the commercial population is it all boils down to plan design and what is the consumer going to be responsible for after a service is rendered. So if you think about a family deductible at 3,500 or 5,000, and you have a 45, or 50 year old diabetic who definitely needs a care manager. That family is now paying out of pocket until their deductibles are met. And that's just unrealistic, right?

 

Daniel Marino: Unrealistic. Absolutely. Yeah.

 

Lisa Stockdale: Though this reduces their overall cost, it keeps their health outcomes in play. We, as providers, are really struggled by the constraints of the plan, design, and what the patient responsibility ends up being. And so, if I could implore anybody that might be listening on the payer side, that is something. We hope that you look at similar to how CMS is treating care management like a primary care service.

 

Daniel Marino: It should be a cost of doing business, and I'll tell you we've negotiated quite a few contracts, both fee for service and fee for value, and all of our fee for value contracts we incorporate care management services as an element of the plan design that should. It's a cost of doing business, it should not be costs that are shared with the patient. It should be as a result of you, providing more efficient care and reducing the overall cost of care, and I think you probably share the same philosophy.

 

Lisa Stockdale: Yes, you can never know go wrong investing in primary care, investing in care management. You're going to get the results that you need in the long run.

 

Daniel Marino: Yeah, yeah, that's it. That's absolutely true. So as we for any of our listeners who are who are tuning in and obviously care management, especially for those that are heavily involved in in population health and value-based care. Any piece of advice that you would give them, maybe from lessons learned, or things that have worked for you?

 

Lisa Stockdale: Don't give up. Yeah, you know. have a strong voice. If it's the right thing to do, you should keep fighting for it. There are patients and communities that need you out there. So you may be that you know, voice off to the side. But please keep going, partner with your finance teams, partner with your physicians. You know, this is not what problem that's going to be solved in silos and operational alignment because nothing is successful. Everything's an idea until it actually is put around operations is put around it. Having those partners is critical to the success that we have. My operations partner is really a dream, and I'm so grateful for her because she's taught me so much around running medical groups and making this program just what it is today. So it's really about having good partners.

 

Daniel Marino: Well. And I absolutely agree, as I've said in working with many organizations around the country, every care management program is unique. But there are foundations, foundational elements of care management that drive the results. And you don't have to reinvent the wheel. I think you've got there. There are lessons learned, the technology partner is important. The data is important. Educating your team is important. And I think, as any organization builds strong care, management and perfect examples with you the support that you provide to your physicians and clinicians. That's what drives the results.

 

Lisa Stockdale: I love it. I walk into my physician offices, and they hug me. We didn't have any of these programs until you got here, Lisa. And so it really is my love for the for primary care for the community here and for my physician partners that I've worked with for the last 10 years.

 

Daniel Marino: You’re definitely passionate about it, and that that comes that definitely comes through. So if any of our listeners are interested in connecting with you anything you share. I'm assuming you're on LinkedIn.

 

Lisa Stockdale: Yes, LinkedIn’s probably the best way to find me under Lisa Stockdale.

 

Daniel Marino: Good. Well, we will include your LinkedIn handle in our liner notes. And Lisa, this has been great conversation. Thank you for coming on and sharing your stories, and and your successes, and I wish you a lot of future successes as you continue to evolve your care management.

 

Lisa Stockdale: I appreciate you, Dan. Thank you for having me on today.

 

Daniel Marino: And a special thank you to you, our listeners for tuning in. Until our next insight, I am Daniel Marino, bringing you 30 minutes of value to your day. Take care.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners