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Managing Beneficiaries

OIG Series Blog 3: Managing Beneficiaries with Costly or Complex Care Needs

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As a former bedside ICU nurse, I have witnessed numerous patients who reached a breaking point in their condition management. Whether their worsening was related to overlooked social determinants or the neglect of their treatment, I am a witness to the impact of proper care coordination when it comes to managing the highest-risk beneficiaries.

Careful coordination not only positively affects patients but results in tremendous reductions in spending from the value-based care perspective. Today, we are continuing our advisor analysis of the latest Office of Inspector General (OIG) report about 20 high-performing accountable care organizations (ACOs) who each earned well-deserved recognition for their savings and improved health outcomes.

Two Procedural Changes

Closer management of beneficiaries with costly or complex care needs is a step all ACOs need to prioritize. The Acting Inspector General of the Department of Health and Human Services, Joanne M. Chiedi, distinguished the ACOs’ success in this third strategy to two significant procedural changes:

  1. The use of care coordinators
  2. Forms of outside care

Both of these changes reformed the way complex patients were cared for to include more personal, private, and cost-effective approaches. They were simple changes, from making a phone call or scheduling a follow-up appointment, to visiting a patient at their home for visits that do not require being in-office.

“Beneficiaries with costly or complex care needs account for a disproportionate amount of total healthcare spending. These beneficiaries—as well as beneficiaries who are at future risk of needing high-cost or complex care—have a wide variety of health conditions, such as diabetes, chronic lung disease, or congestive heart failure.” – Joanne M. Chiedi

The Use of Care Coordinators

Atypical patients require specialized attention. Missed interventions can often lead to higher costs of care down the road and potentially worse outcomes for the individual from inaction. At Lightbeam, we stress the importance of care management at every opportunity, since it has a substantial impact on patient compliance to care plans, medications, appointment attendance, and more. The OIG study confirmed that almost all of the ACOs interviewed use care coordinators to manage large subgroups of patients, and that the coordinators’ duties increase when caring for complex patients.

The ACOs in the study approach care management in a perfected, uncomplicated way that achieves results. Each care coordinator received a tailored list of beneficiaries to take on and ensured that they took the right medication, saw the right doctors and specialists, and made follow-up appointments for them so there would not be any missed opportunities. The care coordinators in these ACOs also helped carry out the prescribed care plans from patients’ physicians to improve overall outcomes.

One ACO went even further for patients who manage complex conditions. In this ACO, coordinators called high-risk patients every day to check on their status and report any changes in their health to the appropriate provider. In these follow-up conversations, if there were any significant changes, a care coordinator could dispatch a nurse or any other needs they required immediately. With these practices in place, the ACO achieved a 43% reduction in emergency visits and a 47% reduction in hospital readmissions.

Forms of Outside Care

Providing care outside of a doctor’s office setting has an undeniable impact on beneficiaries. But, in this context, outside care means more than physically going to a patient’s home. In the OIG study, these ACOs employed two additional forms of care: telephonic services and monitoring devices to keep a closer eye on high-risk patients in between their appointments. Telephonic services allowed patients to have 24-hour access to their care managers should an unexpected event occur. But, it is important not to discount in-person home care. These high-performing ACOs not only sent care coordinators to patients’ homes, but also personnel like pharmacists, specialists, and even their physicians to perform out-of-office services.

Managing Complex Patients

Within our population health management platform, we offer analytics charts that identify high-risk, high-cost patients. The unique Lightbeam Care Management module offers a day-to-day workflow solution to help care managers document care plan steps, stay up to date on patients’ progress, assessments, and other items with the patients they are assigned to manage.

Next time, my colleague Sean will discuss how these ACOs minimized hospitalizations and saved emergency care as a last resort.

The full study can be found at

Jessica Scruton, BSN, RN, CCM, Lightbeam’s VP of Clinical Transformation


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