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Problem:
A selected RPNavigator client wanted to respond
to its Health Plan Association’s proposal to select three model
plans to pilot state-of-the-art care coordination. The model would need to illustrate its capability to identify
and focus on member healthcare needs, member safety, and quality.
The desirable models would leverage the plan’s disease management
programs and case management capabilities for Federal Employee
Service Benefit Plan members. There was an additional expectation that data would guide decision-making
relative to the appropriateness of the care programs and thus the
allocation of resources. The models would, ideally, provide members with a single point of
contact to integrate the management of multiple chronic conditions.
Solution:
Our Client demonstrated the extensive use of RPNavigator’s
broad capabilities in facilitating care coordination.In particular, the Client showed how it used the risk
stratification software to identify:
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Actionable, high-risk members to be referred to the
appropriate care management program through a pre-triage assessment conducted by a non-clinical staff member
- Actionable members with an increased Care Management Index and Gaps in Care, thereby increasing
the efficiency of clinical staff
- Atypical utilization patterns (much higher or lower than
expected) for any member population or subpopulation (e.g. by
disease, employer group, line of business) to better manage and for
outreach to the provider network
- Opportunities to supports quality improvement initiatives
- Provider performance compared to peers, after
case mix and severity adjustment
Results:
- The Health Plan was selected as one of only three model plans
by the Association
- Provided case management services to 4,800 members achieving
a 95% program satisfaction score
- Achieved $5.1 million in program savings
achieving 2 to 1 program ROI
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