Care management is used by health plans and providers to closely manage one or more conditions, such as diabetes, or to prevent an acute event, such as an unnecessary emergency department (ED) visit. ED visits are costly and many visits are preventable. Preventable ED visits are ones that can be handled in a different setting as well as visits that could have been avoided through more appropriate preventive or chronic care management.

Quite often, care management programs are deployed in a reactive manner and don’t spend enough resources to understand the specifics of their patient population. Why do some populations use emergency room visits more than others? Why are outcomes for some cohorts different than others despite the same interventions? or Why is a specific condition more prevalent in one group vs. others? These questions are important to answer to drive maximum output from care management. For example, in the United States, the rates of diagnosed diabetes in adults of all ages, by race/ethnic background, are:

  • 14. 5% of American Indians/ Alaskan Natives
  • 12. 1% of non-Hispanic blacks
  • 11. 8% of Hispanics
  • 9.5% of Asian Americans
  • 7. 4% of non-Hispanic whites
Health disparities in the care management patient population

Similarly, when you compare the ED utilization, individuals in the highest income quartile are significantly less likely than individuals in all other income groups to have an ED visit with any principal diagnosis.

When we looked under the ‘hood’, we found that for non-emergent issues, the most common reasons that drive ED utilization is lack of primary care access, gaps in care coordination, barriers such as transportation, food insecurity, housing, and lack of education, awareness as well as poor health choices. Most of these issues are caused by health disparities. There is no denying that health disparities exist among the common chronic diseases, such as hypertension, diabetes mellitus, HIV/AIDS, cancer, cardiovascular disease, and obesity, with ethnic minorities and the poor having higher incidences or worse outcomes. 

Health disparities are caused by a wide range of factors and can broadly be analyzed into three categories –

Socio-economic: This includes factors like socioeconomic status, education, neighborhood, and physical environment, employment, and social support networks, as well as access to health care.

Geography: This includes limited physical access to health care, but also to differences in demography, attitudes, lifestyle factors, and cultural practices in regional and rural settings. 

Specific characteristics: This includes factors such as race, ethnicity, or sexual orientation.

All three factors contribute to divergent outcomes. The effects of health inequities are multiplied for those who have more than one type of factor.

The solution for reducing health disparities is improving health equity. Finally, after decades of neglect, health equity is getting a lot of attention. In fact, in the 2022 strategic plan, CMS has made health equity their first pillar.

Health equity means the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes.

Centers for Medicare & Medicaid Services

Understanding and solving health disparities is complex and is influenced by interdependencies of multiple factors such as income, housing, environment, transport, education, and work. Providers are not always aware of the healthcare barriers their patients face.

Case managers can leverage digital care management solution as an effective tool to manage the avoidable differences in health outcomes experienced by people who are disadvantaged or underserved, and provide the care and support that people need to thrive. This technology-based solution provides data ingestion and filtering capabilities to understand the differences in the patient population by race, ethnicity, preferred language, sexual orientation, gender identity, disability, income, geography, and others. It is built on a strong data foundation that collects and integrates data from multiple data sources (claims, clinical notes, labs, imaging, ADT, etc.) and creates a single unified patient record with data across the healthcare continuum.

The digital care management solution uses a smartphone as a scalable and intimate channel to transform this episodic care into a more connected daily support model. This enables care managers to stay connected with many more patients and build much stronger relationships with them. Contrary to the common perception, the minority populations in the United States have the highest rate of smartphone ownership with Asian/Pacific Islanders (86.6%), Black-African Americans (83%), and Hispanics (82.4%) as the top three groups, compared with 74.2% of non-Hispanic whites.

Digital care management also includes modern tools to design personalized care plans and coordinate care across multiple settings. It embeds methods to address social determinants into clinical care pathways. This includes customizing interventions to include provision for technical assistance and education to disadvantaged communities as well as effective coordination with community-based organizations.

Digital care management and patient engagement

These care plans are delivered directly to patients’ phones, giving them simple interactive guidance every single day, to help them along the way and get back to life. Patients can also send messages to their care managers in-between scheduled visits. The patient app downloaded on a smartphone makes it easy to collect data via digital assessments to assess risk factors, such as poorly controlled chronic medical or behavioral health issues, or social determinants such as unemployment, and housing insecurity. This model is highly engaging. Due to this engagement, the care managers can learn what their patients’ needs are, and what they are struggling with and so they can respond to these evolving needs faster and change the care plan if needed. In addition, the digital care management solution captures a large amount of data from patients’ interactions with their mobile clinical programs, as well as from interactions with their care teams. By applying analytics to this critical data, the solution creates unique insights into patient needs and behaviors, insights that extend far beyond the four walls of in-person care. It also leverages predictive analytics to proactively understand the unique characteristics of each cohort and their correlation to ED utilization.

Payers and providers can now take a whole-person approach to address and support the needs of patients with equity gaps with an integrated care management solution that blends clinical care delivered virtually, ongoing support delivered digitally, combined with social care that connects them to federal, state, and local benefits – real steps toward health equity.