Catalyze efficiency and collaboration through clearly defined processes and appropriate technology utilization.

Define and mobilize organizational efficiency

For Utilization Management (UM) and Care Management (CM) organizations, the need to drive member activation and engagement has never been more apparent. Given current market demands and the shift to value-based care, UM and CM departments are increasingly confronted with the need to demonstrate their ability to drive member engagement in their personal health and care management. Yet, member activation and engagement remains low across health plans.

Health plans and their clinical operations team face unique challenges, often fueled by broader organizational limitations and inefficiencies. UM and CM departments, despite their need for connectivity, are generally siloed and often fragmented across Inpatient and Outpatient settings. In addition, broader organizational inefficiencies spanning people, process, and technology also impact UM/CM effectiveness:

  • Undefined benchmarks and reporting deficiencies
  • Redundant and duplicated processes
  • Platform limitations resulting in manual and inconsistent processes
  • Numerous data sources exist across the organization creating data access gaps
  • Processes and coordination between departments and facilities are limited
  • Technology capabilities and tools are not fully leveraged across the organization

Solution Approach and Strategic Roadmap Development

The West Monroe team engages with our health plan clients via a three-step process to assess their UM and CM capabilities across people, process, and technology and define the ideal structure to enable member activation in care management programs and health behavior change. We work to pinpoint current limitations and then identify the capabilities required to improve program effectiveness. Our tailored approach enables the development of a tactical, strategic roadmap that paves the way for the flexible technology and operations-based solutions needed to bring the ideal vision to life.

ANALYZE

We analyze and assess the current state and identify areas for improvement by assessing current processes, available data, and technologies.

  • Conduct interviews with key stakeholders
  • Perform rapid review of organizational documentation and reports
  • Consolidate observations and identify themes 

IDENTIFY

We identify opportunities and address current organizational gaps by quickly mobilizing implementation efforts involving people, process and technology gaps identified. 

  • Conduct data analyses to validate observations
  • Develop initiatives and define effort to deliver initiatives through establishing measurement mechanisms
  • Coordinate and facilitate socialization of findings and opportunities
  • Coordinate kickoffs and establish measurement mechanisms w Develop a roadmap through a deep-dive analysis of preliminary findings

DEFINE

We define and prioritize an actionable, multi-year strategic roadmap.

  • Complete stakeholder review and validation to incorporate feedback for recommended initiatives 
  • Conduct a deep-dive analysis of preliminary findings to define prioritized improvement roadmap 

The Results

Our tailored approach blends people, process, and technology to uncover opportunities and produce a clear path forward for organizational change, operations improvement, and more accurate reporting. For CM and UM specifically, our team: 

  • Aligns care management operating needs across UM, CM, DM and Claims
  • Identify opportunities to decrease total cost of care, IP cost of care/PMPM; increased IP capacity for revenue generating patients, improved PMPM, and eliminate redundancies
  • Identifies success measures to consistently monitor, drive, and measure clinical performance of clinical outcomes (e.g., HEDIS, ED, readmission rates)
  • Reveals the ability to integrate care management capabilities from the perspective of operations and technology
  • Develops a population care management operating model that integrates care management functions
  • Aligns and identifies technology opportunities for population care management
  • Aligns data and analytics strategy to a holistic health management structure

 

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