Editor's note: This story was updated on May 28, 2019.

By Jacqueline Kimmell, Senior Analyst

Care management programs offer organizations a proven way to improve patient health by guiding patients through behavioral change. Care managers help patients identify healthier habits, provide skills-based education on how to adopt changes, reinforce new behaviors, and, hopefully, ensure that patients maintain these lifestyle shifts. Ideally, this process allows the patient to live a healthier life and decrease their unnecessary health care utilization—generating cost savings for the organization.

Webconference tomorrow: Care Management 101

However, this process is often hard. Although most hospital leaders understand the importance of a robust strategy for supporting patients through care management, putting it into practice can be a daunting task. In fact, Tomi Ogundimu, a practice manager with Advisory Board’s Population Health Advisor, says that many well-intentioned organizations will fall victim to five common pitfalls in identifying, assigning, and graduating care management patients, which may ultimately reduce their chances of success.

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Keep reading to learn how you can avoid those common pitfalls.

5 common pitfalls that can doom your ambulatory care management strategy

Advisory Board has found five well-intentioned mistakes organizations make in their care management programs— and evidence-backed solutions your organization should adopt instead.

1. Focusing exclusively on high-risk patients: As high-risk patients tend to be the most costly to the health system, many population health managers will start their programs by focusing on these patients in an effort to achieve the greatest financial returns.
   
   

   The problem: While these patients are often the most costly, they are also typically the hardest to manage. Many high-risk patients may have five or more chronic conditions that can involve complex care plans and make both success—and financial savings—difficult to maintain.

   A more robust solution: More sustainable cost savings can come from focusing on moderate-risk patients whose inappropriate utilization of care and development of chronic conditions can be prevented down the line. As new patients jump into the high-risk category every day—about 18% of rising-risk patients each year—slowing down the flow of rising- and low-risk patients into this category is foundational for long-term cost savings.

2. Not involving primary care doctors in patient selection: Leaders of care management programs may view themselves as separate from the clinical team and thus may feel uncomfortable reaching out to providers when selecting candidates for care management. Alternatively, they may feel providers are too busy to be involved.
   
   

   The problem: Leaving doctors out of the care management process can alienate them from the program, which can hurt later chances of the program's success. In addition, keeping providers out of the loop could mean care management teams overlook patients who could benefit from the program.

   A more robust solution: Because doctors often have closer, personal relationships with patients, they likely have a greater ability to identify who would or wouldn't be a good candidate for a care management program. At a minimum, care management programs should have a patient's primary provider endorse that they're right for care management. However, many programs have standards for care managers to follow-up with primary care providers in consistent intervals to review the patient's care plan and progress.

3. Assigning case managers based on disease type alone: Assigning care managers to all patients with, for instance, diabetes, seems like an efficient way to streamline services and clearly divide staff.
   
   

   The problem: When patients have multiple chronic conditions, a disease-by-disease care management model can quickly become redundant and result in multiple care managers reaching out to the same patients to manage similar care needs.

   A more robust solution: While assigning care managers based on disease type may be a good starting point, more efficient models will dive deeper. Advanced programs will first create explicit inclusion and exclusion criteria for which patients should be targeted for the program. They will then determine how to deploy the care team to account for target population size, primary method of patient communication (i.e., in-person, telephonically, or virtually), and the engagement of primary care providers.  For example, a better patient assignment methodology might first divide patients by setting, then by type of care, primary care provider and, finally, acuity type.

   
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4. Not knowing when to stop patient outreach: For patients who would be excellent candidates for care management, it can be tempting to 'do whatever it takes' to enroll them in the program. Case managers may continuously reach out to targeted patients in the hope that the next attempt could be the one that gets the patient to enroll.
   
   

   The problem: Many patients are simply not able or interested in enrolling in care management programs, even despite the care team's best attempts.

   A more robust solution: Programs should have standards for how many outreach attempts case managers should undertake. For example, as part of Partners HealthCare's flexible recruitment process, a care manager calls new patients up to three times. After the third time, the care manager stops calling. However, the onboarding system is flexible enough that if the patient proactively reaches back out, the care manager can still enroll him or her.

5. Not having standards for when to graduate patients from the program. Many patients form deep connections with their care managers—making managers hesitant to scale down their contact with these patients. Additionally, many managers may be tempted to maintain a high level of engagement with patients to ensure they follow through with their care plans.
   
   

   The problem: Ogundimu remarks that, "when we first started looking at longitudinal care management, I was surprised to learn that not only do some high-utilizing patients get attached to these care managers, but sometimes the care managers get attached to their patients themselves." She explains that this attachment can lead to remarkable behavioral change—but can also burden care managers who, although new patients are entering their caseload, cannot 'offload' older patients who should have already graduated from the program.

   A more robust solution: As Ogundimu explains, "Patient graduation is an important milestone of achievement for both the patient and their care team. It is best to set the expectation of graduation from the beginning in order to ease a patient's transition to self-management and help frontline care managers accommodate sustainable caseloads."

Webconference tomorrow: Care Management 101

In the second installment of our "Population Health 101" webconference series, join us tomorrow at 1 pm ET for an introductory review of the five key attributes of effective care management organizations—from patient recruitment to graduation.

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