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Implement an Intelligent Care Management System

Learning Objectives

After completing this unit, you’ll be able to:
  • Describe how Social Determinants of Health provide a complete picture of the member.
  • Describe how Member 360 is used to create individualized Care Plans.
  • Explain how Utilization Management uses proactive strategies for better health outcomes.

Read Between the Lines

After a checkup, a nutritionist can prescribe a personalized diet for a patient suffering from chronic stomach problems. But that effort is lost if the member is in no position to follow through because they live in an environment where there is a lack of food security.

Social determinants of health are the circumstances in which people are born, grow up, live, and age. In addition to access to healthcare, they include physical environment, food security, housing, education, and employment. Social determinants of health are so critical that they impact 80–90 percent of health outcomes. Payers and providers must identify risks, determinants, and barriers to health to care for high-risk, high-need members and offer timely interventions.

Health Cloud makes it easy to track, monitor, and assess potential challenges. It offers personalized workflows and tools to help tackle each issue. Case managers can view previous survey responses for deeper insights into the member profile and reactivate older determinants. With this data, they can measure the barriers and set up interventions to overcome the challenges.

Page showing Social Determinants of Health for Charles, with Care Barrier Type.

As part of the care program, Charles was asked to take part in a survey on patient preferences. From his responses, it’s apparent that he doesn’t have a car and relies on public transportation to reach the pharmacy. Because his back pain makes it difficult for him to travel, picking up medication on time is difficult for him. This is a care barrier.

Charles’s care program team intervenes by logging a case to find a ride service covered by Charles’s health insurance provider. By securing transportation for Charles, the care program team helps him overcome his transportation barrier.

Page showing Social Determinants of Health for Charles, with intervention to overcome care barrier.

Become a Precision Payer

To stay on the frontlines of medical treatment, healthcare professionals aim to provide precision medicine that is proactive and accurate. Instead of a one-size-fits-all approach, precision medicine combines genomics and pharmacology to provide customized medication. As a result, medical treatment has shifted from reactive to preventive with more effective treatments and reduced costs.

On the right side, the shape of a pill within shape of a human; on the left side, a stack of Care Plans, Problems, Goals, and Tasks within the shape of a human.

Health Cloud empowers payers to learn from precision medicine and become precision-driven payers. The goal is to not only use clinical data, but also to look at factors such as household relationship maps, social determinants of health, and claims and benefits information, to create a customized care roadmap.

Case managers have a comprehensive understanding of the members in the Health Cloud console with health metrics pulled in from multiple sources. The single view makes it easy for case managers to create flexible, personalized Care Plans with measurable, practical goals and tasks to help members stay on top of health goals. Care Plans are also tagged to case teams, which supervise a member’s health journey.

Problems, Goals, and Tasks created as part of a Care Plan for Charles.

But that’s not all. Case managers can use Health Cloud add-ons such as Einstein Analytics to monitor care plan adherence and get a snapshot of members who fall behind on tasks assigned to them. Einstein offers informative dashboards and visualizations of members’ risk profiles using overdue tasks to identify high-risk members who need support to reengage with their health journeys.

Einstein Analytics showing graphs that represent Member Risk Profile by Overdue tasks, Number of Goals Overdue, and Number of Tasks Overdue.

Together with Risk Stratification, Einstein Analytics can also help identify Care Gaps. You can add Care Gaps to Patient Cards so that case managers can easily track and monitor gaps for better health outcomes. Using insights from the dashboard and real-time analytics, case managers can take actionable steps to supervise Care Plans and remove Care Gaps.

Charles Green’s case manager uses all the resources available to Salesforce Health Cloud, including his medical records, survey responses, household map, and Social Determinants of Health, to create a personalized Care Plan for him. His plan calls for him to go for physical therapy sessions three times a week. He is assigned a goal titled Lifestyle Changes to help him get more physically active. His case manager also sets up a task called Morning Walk. After a few weeks, his case manager notices overdue tasks in his Care Plan. Because there is no park in his neighborhood and he has to walk a few blocks to reach a park, Charles finds it difficult to complete this task. His case manager records a Care Gap and discusses other alternatives with his care team. Charles is assigned a new task, 1000 Steps a Day, that he can do at home.

Deliver in a Flash

In the past, Charles would wait a week for his claims approvals. Now with Health Cloud, call center agents have Utilization Management on the Member 360 platform. This feature provides a single, unified channel so agents no longer switch systems to get data. All member information, prior interactions, and background details are available in one place.

Utilization Management in the Health Cloud Console that presents clinical data, Social Determinants of Health, and member plans on a single platform.

Utilization Management also lets you automate decisions based on medical policy, monitor service-level agreements (SLAs), manage appeals, use claims visualization, and reduce manual intervention. It streamlines the authorization process using collaborative, measurable workflows. You can create appeals, complaints, and grievances easily and tag them to the appropriate teams for processing.

Utilization Management in the Health Cloud Console showing list of Care Requests by Charles.

But Utilization Management does even more. Imagine fast-forwarding to the future and seeing the outcome of your actions. You could make smarter decisions, cut down on actions that aren’t helpful, boost productivity, and become super efficient.

With Utilization Management, providers don’t contend with medical necessity reviews done post-service that cause reimbursement delays. Payers can easily gather clinical data from providers and evaluate cases for medical necessity preservice. With access to Member 360, clinical professionals such as a registered nurse or a pharmacist can review the member’s medical information from the provider. They can also check if the member’s plan covers the care request by checking the benefits. If a care request does not qualify as a medical necessity in the clinical professional’s review, it gets a second-level evaluation by medical directors. A two-level review and proactive prior authorizations lead to better health outcomes and fewer errors in treatment.

Back to Charles Green. Charles uses Provider Search to get a second opinion about his lower back pain. The new provider suggests herniated disc surgery and creates a care request for Charles. Melinda, the Utilization Management clinical professional is assigned to Charles’s care request. With a 360-degree view of Charles’s medical records, she can see all the information submitted with the request, along with nonclinical data such as benefits, existing authorization, and policies. After a thorough review, Melinda decides that the care request is not medically necessary. Now the request goes to Barbara, a medical director, who’s in charge of reviewing the care request. Like Melinda, she too has a 360-degree view of Charles’s medical history. After assessing his entire profile, Barbara agrees with Melinda’s opinion that surgery is not a medical necessity for Charles. His care request is denied and Barbara provides the explanation for the denial that gets communicated to the provider.

With its member-centric approach to healthcare, Salesforce can support you on your mission to provide the highest level of care to your members. At the same time, Health Cloud’s intelligent analytics ensures proactive intervention and continuation of care.

Good health equals happiness, and Health Cloud with its gamut of intuitive functions supports you to give your members the gift of happiness.


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