Purpose: To describe the development and implementation of Rush Health’s care management (CM) program for primary care patients and the efficacy of strategic value-based care initiatives as it pertains to addressing patient chronicity and utilization trends.

Description: The whispered concept of value-based care began circulating throughout the healthcare industry roughly ten years ago and over time has grown louder into a large roar, impacting how healthcare organizations are rewarded for performance. The shift from fee-for-service to fee-for-value broke tradition and thus mobilized healthcare leaders to think of innovative strategies to ensure better results as it relates to quality, cost, and outcome measures. One approach proven effective in addressing the triple aim and improving the health of populations is the implementation of care management (CM) programs in primary care settings (Agency for Healthcare Research and Quality, 2015).

Rush Health, an affiliate of Rush University System for Health, thrives on innovation and proactively took on the challenge of embracing value-based care. In 2016, Rush Health, a clinically integrated network of physicians and hospitals, began overseeing several value-based care payer contracts where CM services are a requirement for reimbursement. In less than two years, Rush Health developed a CM program utilizing evidence-based research to effectively address primary care patients’ needs; teams of nurses, social workers, and other allied health professionals focus their activities on care transitions, disease management, abhorrent utilization, and care gap closure.
During the development of the CM program, emphasis was placed on incorporating both qualitative and quantitative resources to ensure proper identification of high-cost patients. The inclusion of holistic and patient-centered approaches to health was also of importance as this yielded comparison to other best practice models (Healthcare Transformation Task Force, 2018). Evidence-based health assessments were developed internally along with real-time discharge notifications and a comprehensive report that combines multiple patient data points and assigns “red flags” as risk indicators for care managers. The program also piloted an emergency department (ED) alternative mailing project to help redirect patients at risk for abhorrent utilization to urgent care.

With the help of actionable data, CM teams conduct patient outreach, complete assessments, follow up after discharges, and create care plans to proactively identify and address barriers to care. Today, the number of payer contracts has grown to account for over 100,000 patient lives, and the CM program has since been adopted by all Rush Health network members.

Evaluation/outcome: Due to the structure of Rush Health’s CM program, several payer contracts saw shared savings including a 17.5% per member per month savings ($757,750 annualized savings) for the management of a diabetic population in 2018. Regarding the targeted ED mailing pilot, there was a 1.6% decrease in ED visits during the three-month pilot compared to the control group who did not receive the mailing. In conclusion, there were documented cost savings and effective population health management since the inception of Rush Health’s CM program, indicating that the program’s design is directionally effective. Rush Health continues to optimize and monitor the program’s efficacy for future expansion.

Ashley Prentice MBA, BSN, RN

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