The care management team concept has evolved over the last decade to be more patient- and data-driven. Truly modern care management teams—those that represent the future of care management—provide team-based care that is carefully planned, comprehensive, highly coordinated, data driven, evidence based, seamless, and patient centric. But what’s equally important as being patient-centric and patient-driven, is relying on a comprehensive, effective care management system—a suite of tools with features in five core competencies: Data integration. Patient stratification and intake. Care coordination. Patient engagement. Performance measurement. As the industry’s care management teams continue to evolve (e.g., using predictive analytics to proactively identify patients), their primary goal remains: achieving optimal outcomes for the patients they serve.

1. The Modern Care Management Team:
Tools and Strategies Evolve, but the Outcomes
Improvement Goal Remains - Dr. John Haughom

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The Modern Care Management Team
As he sips his morning coffee, Dr. Peter Touché reflects on his journey.
When he finished his primary care training in 2010 and joined a large
health system’s medical group, a more modern concept of care
management was beginning to emerge.
But his health system didn’t launch a more
up-to-date care management initiative
until two years later.
Now, eight years after entering practice, that
care management program is in full bloom.

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The Modern Care Management Team: What Does It Look Like?
The care management team concept has
significantly changed and expanded over
the last decade.
Rather than consisting primarily of himself
and his office nurse, Dr. Touché’s panel of
patients are now assigned to a considerably
larger provider panel, which he leads.
This provider panel consists of specialty
physicians, care management nurses,
therapists, social workers, nutritionists,
educators, and others.

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The Modern Care Management Team: What Does It Look Like?
Under Dr. Touché’s leadership, the care
team and his panel of patients view each
other as partners in care.
With the care team’s support, patients are
encouraged to enhance their roles in
care planning, decision making, self-
management, and the adoption
of critically important health-related
behaviors.
Dr. Touché’s care team is characterized
by important criteria, beyond simply
being larger in size:

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The Modern Care Management Team: What Does It Look Like?
All team participants know and accept that they are part
of a large and diverse team in service to patients.
Patients and their families are viewed as integral parts
of the care team.
The care team depends on frequent, effective
communication between each member, including
patients and families.
The team has a comprehensive awareness of what
each member is accountable for and what they are
achieving to prevent gaps in care and avoid duplication.
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The Modern Care Management Team: What Does It Look Like?
Dr. Touché’s care team meets regularly to
manage existing patients, assign new
ones, and review and update assignments
for each care team member based on each
patient’s needs, values, and preferences.
Tasks are assigned based on each team
member’s skills, abilities, and credentials.
Care team members are guaranteed
protected time to conduct activities
beyond direct patient care, including
continuing education to stay current
with clinical advances and constantly
updating clinical protocols.

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The Modern Care Management Team: What Does It Look Like?
The approach taken by Dr. Touché’s care team is consistent with the
Agency for Healthcare Research and Quality’s (AHRQ) published
definition of patient-centered primary care as:
…care that is relationship-based with an orientation toward
the whole person, and that includes partnering with patients
and their families to understand and respect each patient’s
unique needs, culture, values, and preferences.
Care that is patient-centered also supports
patients in learning to manage, organize,
and participate in their own care at the
level the patient chooses.”

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The Modern Care Management Team: What Does It Look Like?
The modern care management team’s goal is to provide team-based
care that is carefully planned, comprehensive, highly coordinated, data
driven, evidence based, seamless, and
patient centric in pursuit of optimal
outcomes for the patients they
serve—a goal that requires a
comprehensive, effective
care management system.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
As care teams continue to modernize and
evolve, their reliance on effective, compre-
hensive care management systems will
continue to grow.
Systems that integrate healthcare data from
all sources, stratify patient risk, organize
patient intake, manage patients through
comprehensive care coordination, present
two-way communication between patients
and care managers, and measure care
team performance.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
The technology to support care manage-
ment begins with the EMR, but goes far
beyond the mere digitization of a patient’s
medical history.
While EMRs are necessary sources for
collecting and storing data, they are not
the interactive workflow tool clinicians need
for timely and judicious decision making.
What’s needed is a suite of tools with
features in all five core competencies of
care management:

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Modern Care Management Teams Require
Comprehensive Care Management Systems
Data
Integration
The ability to pull data from multiple EMRs and other data sources, then
aggregate, analyze, and make it available to the right people at the
right time.
Patient
Stratification
and Intake
Using analytics-driven decision making to identify high-risk, high-utilization
patients. This tool also supplies care managers with prioritized worklists
for interventions, and greatly simplifies their work.
Care
Coordination
The timely, all-inclusive care team communication and collaboration on
patient assessments, care planning, and interventions.
Patient
Engagement
Informing patients about their care planning and facilitating interaction
among all care team members through application-based secure
messaging, assessments, care planning and associated activities,
and education.
Performance
Measurement
Advanced reporting capabilities to show how the care team performed
after analyzing and acting on the data provided.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
In addition to the tools comprising a
comprehensive care management
system, two other factors are
important in determining the value
and effectiveness of a care
management system.
First, the care management system
must have access to all necessary
data, including data from the health
system’s EMR and other systems that
provide operational, financial, cost,
and satisfaction data.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
It is also important to include patient-reported
outcomes (PROs) as they become available.
Typically, this is data integrated in a well-
designed enterprise data warehouse (EDW).
Second, the care management system must
have advanced healthcare analytics
capabilities.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
The system must be able to analyze data to
figure out trends and patterns that drive
better outcomes for patients and change the
day-to-day workflow for clinicians.
Embedding advanced analytics capabilities,
including predictive analytics and machine
learning, coupled with data-driven quality
improvement methods is critical to success.

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Modern Care Management Teams Require
Comprehensive Care Management Systems
Fortunately, Dr. Touché’s care team has
access to a care management system
with these capabilities.
They use the information during their
meetings to establish and monitor
metrics (especially for chronic disease
populations), and proactively identify
and track patients by disease, risk,
clinical, and functional status.

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Care Management Teams Evolve but the Goal Remains:
Improve Patient Outcomes
Because of this new care management model, Dr. Touché’s
panel of patients has substantially expanded from
approximately 2,000 to several thousand.
Yet, despite this growth, he believes
the care management team is delivering
even better care—a significantly more
satisfying type of practice than he
experienced when he first joined
the health system.

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Care Management Teams Evolve but the Goal Remains:
Improve Patient Outcomes
He feels more in control and enjoys working
with his peers on the care team.
And, most importantly, objective data points
to improved patient outcomes, especially for
chronic disease patients.
As he finishes his coffee, Dr. Touché feels
a deep sense of satisfaction.
This is care management as it should be!

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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John Haughom, MD, is an experienced healthcare executive with proven expertise in technology-
enabled innovation, developing results-oriented strategic plans, leading multifaceted organization-
wide change, and directing complex operations. He has a strong record of turning vision into
effective strategies and successfully implementing initiatives resulting in value including higher
quality, safer care at the lowest possible cost. His broad knowledge of healthcare and emerging
healthcare technologies is coupled with his recognized leadership abilities, strong communication
skills, and demonstrated ability to contribute to organizational goals such as improved clinical outcomes, lower
costs, improved access to care, and increased profitability. After practicing for 15 years as an internist and
gastroenterologist, Dr. Haughom assumed a senior executive role with responsibilities for system-wide
automation, budgeting, customer support, database administration, healthcare delivery, information technology,
quality control, research, safety, and strategic planning. Dr. Haughom became President and CEO of a firm
focused on health care transformation through consulting, strategic planning, mentoring inexperienced physician
leaders, involvement in regional and national reform movements, membership on boards of leading edge
organizations committed to improving the value of healthcare, and partnership with other like-minded
organizations with similar aspirations and goals. As Senior Vice President of Clinical Quality and Patient Safety
for the premiere health care system in the Northwest spanning three states (Oregon, Washington and Alaska),
Dr. Haughom developed and implemented a system-wide quality improvement strategy, comprehensive patient
safety plan, and comprehensive system-wide information technology strategy.
Other Clinical Quality Improvement Resources
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