Issue link: https://beckershealthcare.uberflip.com/i/644565
68 Executive Briefing care managers and other members of the care management team — such as community health workers, social workers and health coaches — must be prepared to proactively identify high- risk patients and intervene at the first sign of health problems. "Embedded care managers become an accepted part of the care team and can facilitate more timely interactions with physi- cians and staff when they receive important patient information," says Steven B. Pierdon, MD, senior medical director of xG Health. xG Health Solutions created xGCare, a care management soft- ware platform, to streamline the key components of an efficient care management model. xGCare supports the care manage- ment team by consistently delivering best practices for patients with complex needs, multiple conditions, chronic conditions and during transitions of care. xGCare comes with multiple features to enhance care manage- ment, such as evidence-based patient assessments for 35 con- ditions and rules that automate the production of patient-spe- cific action plans. xGCare produces streamlined workflows, stratifies patients based on risk, provides data analytics-driven decision support and organizes tasks for care managers, in- cluding identifying patients in need of alerts and reminders. The platform also enables supervisors to monitor the perfor- mance of individual care managers, including their caseload distribution and productivity. xGCare organizes a care manag- er's workflow and priorities for the day, updating these in real time based on patients' risk. "A care management platform needs to not only guide a care manager on the question, 'What is the right thing to do?' but also to know when that interven- tion or outreach is due," says Dr. Aggarwal. Data analytics that enable the care management team to deliver the right care to the right patient at the right time is an integral feature of a care management platform. To determine each patient's risk, xG Health runs each client's membership and claims data through risk stratification software to obtain prospective risk scores. These scores are then combined with certain condition- and time-related metrics to produce a list of patients requiring care management. Once the highest-risk patients are identified for care manage- ment, real-time alerts and decision support guide the care managers through care pathways. Patients are typically flagged for different care management programs, such as complex case management, disease management, gaps in care and others, says Dr. Aggarwal. "For example, weight gain in a heart failure patient will lead to an automated care plan," says Dr. Aggarwal. "The care plan will help the nurse increase the diuretic medication, which is part of the provider-directed heart failure management plan. This can help prevent an emergency room visit." The Importance of Education in Care Management and Care Redesign Any change to clinical pathways and workflows requires phy- sicians, nurses and non-clinical staff to make adjustments in their daily practices. This typically requires a greater focus on education and team member support. To address this need, xG Health created xGLearn, an educa- tional platform that guides the implementation of ProvenCare, xGCare and the training of effective care managers. xGLearn combines collaborative technology with distance learning to help providers and health plans quickly develop effective care management teams. xGLearn includes expert-narrated mod- ules, self-guided activities, individual and small group coach- ing sessions, social learning and pre- and post-evaluations. Students also have live interactions with experienced Geisinger and xG Health clinicians, who teach the care team to think col- laboratively and develop critical decision-making skills. xGLearn modules are accessible around the clock on a variety of electronic devices, allowing education to fit into each indi- vidual's busy schedule. "Organizations can review these processes at their own pace, 24/7 on the Internet," says Ms. Horgan. "This allows students to view any particular stage of the process multiple times, and allows the project leader to review [next stages] in advance and prepare the team." Conclusion Developing a robust care management program and under- taking care redesign requires subject matter expertise, experi- ence, system wide buy-in and strong leadership. The increasing pressure for providers to assume more risk and accountability for patients' health is driving them to take the plunge. Now, with solutions like ProvenCare for care redesign, xG- Care for care management and xGLearn to provide training, healthcare organizations can embark on their journeys toward value-based care with confidence and support. n Sponsored by: xG Health Solutions powers long-term success for healthcare organizations with analysis, care redesign, technology, and unmatched depth of expertise. We have roots in one of America's most innovative and successful health systems, Geisinger Health System, and our clinician-led man- agement team has had multidimensional experience at Geisinger and other leadinginstitutions. Our solutions span care management, care redesign, population health analytics, and bundled payments, while our products — xGLearn, xGCare, EnrG|Apps, ProvenCare and ProvenHealth Navigator — scale and expedite change for our clients. For more information, see xghealth.com.