Community Care of North Carolina is working to provide next-generation community care with population health and care management. The state's Medicaid case management program, which provides interventions for high-risk patients, is already showing signs of changing the paradigm of community care among its 1.7 million Medicaid members and anticipated Medicare Advantage enrollees. 

That means turning care delivery upside-down by designing a strategy that supports risk profiling and proactive outreach to the state’s most vulnerable and underserved populations, according to Jamie Philyaw, vice president of care management at Community Care of North Carolina.

"Historically, a disjointed care delivery system has made it too easy for these patients to fly under the radar or fall through the cracks," Philyaw said. 

Executives recognized that early success doesn’t equate to long-term sustainability. As the team considered how to overcome traditional barriers to reaching constituents, it became clear that the organization needed an infrastructure that would support and drive efficiencies around "whole person" patient-centered care. 

CCNC implemented a pop health and care management platform from New York City-based VirtualHealth, which also develops predictive analytics and reporting technologies.

Population health is a critical driver of value-based care, of course: Other vendors of care management systems include Caradigm, Cerner, Enli Health Intelligence, Forward Health Group, Geneia, GSI Health, Health Catalyst, Lumeris, Medecision, Optum, Transcend Insights and Wellcentive.

While the pop health and care management efforts played a key role in the billion-dollar savings, CCNC also achieved those results as part of its organization-wide effort. 

With the new infrastructure in place, CCNC is better positioned for proactive care management strategies by equipping providers with actionable insights into both clinical and behavioral risk factors, as well as addressing the unique social needs of its highly complex populations, said Philyaw.

Care management teams reaching out to members and enrollees can draw on a "whole person" view of patients to identify care gaps and circumvent the need for high-cost interventions. Through continuous monitoring of patient data, care teams are alerted to changes in conditions or behaviors, empowering them with the data needed to reduce costs and improve the health of the populations they serve.

The system helps a care team address gaps that could hinder optimal care delivery. It does this through an array of care, case and disease management tools, provider and member dashboards, and multi-source integration that staff use to collect and analyze diverse datasets as well as track behavior, appointments, medications, hospitalizations, life skills developments and movement between care environments.

For example, if a patient is regularly presenting to an emergency department, a care manager can intervene and redirect that member to better local resources and educational materials.

CCNC pulls information in real time from disparate sources into an enterprise data warehouse to address a standard set of guidelines for care management activities that include: population stratification, clinical data, community resources, case identification and member assignment, among others. 

“Our teams then work with patients, families and other stakeholders to improve resource utilization and outcomes," said Philyaw. 

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com