AHP Re-designing Care Management for Adult Populations
March 3rd, 2025 | Care Management•NewsThe 2025 Care Management (CM) Redesign focuses on operationalizing a structured, population health approach to identify and manage adult patients who are eligible for and likely to benefit from CM support.
Currently, CM efforts are strongly influenced by the specific needs of each practice, leading to potential inconsistencies in how care management is accessed and provided throughout the network. Such inconsistencies can compromise quality outcomes and lead to higher costs of care. Our plan, therefore, is to clearly define eligibility criteria for patient enrollment in CM programs and to deliver evidence-based interventions provided through a variety of CM pathways aimed at meeting the needs of those living with chronic conditions and complex health needs. Our overall goal is to ensure high-quality care for more patients using an efficient yet patient- and family-centered approach.
Our Population Health platform, Health Catalyst, will be key to our success in this work; patients eligible for specific CM pathways will be identified through Health Catalyst using criteria such as disease-specific conditions, utilization patterns, and risk scores. Standardized training in delivering protocol-guided evidence-based interventions and well-defined role expectations for CMs within a team-based model of care will help ensure consistent delivery of interventions across the network.
Six Care Management pathways have been developed to date, including Congestive Heart Failure (CHF), Diabetes, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Depression, and Complex Care Management. The pathways support both embedded and centralized care management designs, offering flexibility in their implementation. These pathways will be integrated into the Epic system.
This population health approach to Care Management, made possible in large part through our use of Health Catalyst, is consistent with successful ACO care management models throughout the country. It is designed to minimize disruption to current practice-based workflows and to enhance the support you currently receive from AHP’s CM team members, including Registered Nurses, Social Workers, and Data Coordinators. Although not all patients will meet the eligibility criteria for the disease-specific interventions provided through the CM pathways, we look forward to collaborating with you to help ensure that all the patients in your practice receive the care and support they need.
