Care Traffic Control

By Andy Gaudette
Feb. 8, 2017

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I’ve spent the last 13 years designing, developing, and delivering care management software to payers in the healthcare industry. Coming from a different but relatable background in manufacturing automation, I knew I had a lot to learn. I spent three years watching case managers and utilization managers work. I needed to completely understand what they did, and how, before I could attempt to satisfy their needs.

This gave me the nurse’s perspective, rather than my own software developer viewpoint. But what I really developed during the learning process was a sense of empathy and respect for care managers, the job title I now like to refer to as “Care Navigator.” It pained me to watch these overworked people have to use several different, tenuously-connected systems.

I would watch them jump back and forth between the eligibility or claims system, the electronic medical record (EMR), the care management platform, and sometimes a customer relationship management (CRM) system, among others. My goal became giving them one central hub, in essence a mission control center, so that their focus could pivot to the members’ needs rather than satisfying multiple IT systems.

Unfortunately, most healthcare IT vendors have never embraced this approach. Health plans and payers have instead been forced to buy silos of technology. For example, they will have standalone evidence-based guidelines, separate analytics, and standalone EMRs.

As I spend more time in health plans, I’m also seeing a shift in management and organizational thinking in which the CMO and clinical staff are becoming an integral part of the decision-making process. I chalk this change up to the successful pivot to value-based care, and say hooray for that!

But most importantly, I love the fact that the Care Navigator has become an integral part of the entire care team. He or she has the proven skills to communicate and coordinate what is best for the patient or member. Plus, there are always multiple providers and specialists in the mix. Which provider can be expected to do it all? The coordination of all of these complicated variables is why I am coining the term Care Traffic Control to encompass the Care Navigator’s role, and the software tools they use.

When I mentioned silos above, I was referring to them from a technology standpoint, but I also think it’s incredibly important to have the information from these literal and figurative silos flow seamlessly back and forth and through their care traffic control software.

Patient Engagement
Pertinent information originating outside of the Care Navigator’s system needs to be a part of the care traffic control workflow. For example, let’s just take the most recent buzz phrase: “Patient Engagement.” The industry collectively is striving to engage the consumer and get individuals to take an interest in their own healthcare; IT vendors are trying to go about it with technology. That’s a start, but I believe behavioral science is also a necessary element. Let’s use phone calls (IVR), secure emails, and text messaging as examples. It doesn’t make sense to have a separate text messaging application in the health plan that doesn’t integrate tightly into the care traffic control platform, because it’s the Care Navigator ultimately deciding who to text.

Say a Care Navigator wants to communicate with two or three different patients, all at different ages and genders. There may be one modality to communicate with an 83-year-old senior or that senior’s daughter or son, and there likely is a completely different modality of outreach to a Millennial. Millennials may not trust unsolicited information coming to them via text or email, though they might trust an app on their mobile phone with secure log-in and access.

Demographics is a crucial piece the Care Navigator and/or their care traffic control platform has to take into consideration of who they are attempting to reach, and document that. Furthermore, they need to document the reason they are reaching out, and the outcome. The documentation needs to happen not just in notes, but automatically documented in the care traffic control platform as well, which can then drive further automation.

More With Less
Another challenge Care Navigators face is “the need to do more with less.” Baby boomers are about to hit Medicare at increasing rates, the Medicaid population continues to grow, and it is getting more and more difficult to find and retain qualified Care Navigators. Doing more with less means that we need to continue to develop software and technology that enables Care Navigators to spend more time with their patients and members, rather than documenting in, and satisfying, the IT systems.

If one thinks of the care traffic control platform as the sun in a solar system, think of the silos I mention as planets. A great example of this is evidence-based guidelines. It makes complete sense for guidelines to be integrated into the care management platform, as opposed to making the Care Navigator leave the platform, look something up in a separate system, and then come back to the main system.

Another example would be patient education material, of which there are some excellent providers out there, but most health plans don’t have time to develop their own. The ideal approach is to have embedded analytics identify a population, create care plans with interventions and tasks, and one of those tasks automatically pushing out education material to the member. The member receives the material via method of their choice, views it easily, and it is documented in the platform that he or she has viewed it: Such a simple idea, and yet a major timesaver.

So my plea to health plans and IT vendors is to work together to truly integrate your sun (care management system) and planets (EMRs, analytics, patient education) to make the life of the Care Navigator easier so that he or she can focus on their patients/members. That will help us improve care and reduce costs, something we desperately need in our healthcare system.

Andy Gaudette is Senior Vice President at HMS.

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