UPMC is a learning community, also commonly referred to as a learning health system.1 While we learn from research and adopt evidence-based practices into our work, at UPMC, we also pilot innovative health care strategies and collect data on our current programs to see which types of care management strategies provide the best outcomes for our communities—and then we share that information with other health systems.
When the UPMC Health Plan Community Team partnered with the Center for High-Value Health Care—a nonprofit research organization that is a part of UPMC Insurance Services Division—none of our care managers had ever been part of a large research study before. There was a learning curve! We conducted the study to understand how in-person and remote care management programs influence patient-centered outcomes, which type of care delivery works best for different people, and how to better support someone’s involvement in our care management program. We delivered three types of care management—high-touch, high-tech, and optimal discharge planning—and then took a close look at how they impacted our members’ hospital readmission rates, patient activation, and health status.
High-touch: Use of in-person and telephonic modalities, for 4 to 12 months, to engage members in care management.
Face-to-face contact not only gave our care managers the opportunity to complete a thorough and accurate assessment, but it also helped us establish a rapport and earn our members’ trust, encouraging them to work with us to achieve their health care goals. After an in-person enrollment visit, we would continue to provide in-person support for high-touch members throughout their involvement in care management from four months to one year. This included meeting at the member’s home or community, joining them for doctor’s visits, or providing support over the phone as needed. During the COVID-19 pandemic, quarantine restrictions kept us from making face-to-face visits. We adapted our program to incorporate more telephonic support. Although we did not consider total telephonic support as our best practice, we were still able to deliver a wide array of important services to our members during the time of quarantine restrictions.
High-tech: Use of remote patient monitoring (RPM) and telephonic modalities, for 4 to 12 months, to engage members in care management.
The high-tech approach was more challenging not only to implement, but to learn. Before beginning the study, we were introduced to a variety of digital health tools, and we learned how to incorporate the additional digital care management components into our visits and routines, like sending educational videos or checking members’ glucose readings for the day. Our team was willing to adapt, but that did not mean we did not struggle with the learning curve. For our team to provide effective care management using digital tools, we had to learn how to master the tools ourselves. We became superusers, knowing the tools well enough to be able to set up our members and assist them with technology-related issues throughout the course of managing their care. For high-tech members, we conducted video visits and phone calls, made three-way video calls with providers and pharmacists, and sent tailored check-in messages that helped us better understand the symptoms or challenges the member was facing each week. Just like in high-touch, we worked with high-tech members from four months to one year.
Thanks to our new experience with digital tools, when the pandemic struck, we were ready to pivot. Our experience learning about and delivering digital care management from the study startup in April 2018 until the arrival of the COVID-19 pandemic in March 2020 served as a great training for the world of virtual care that began during the COVID-19 quarantine. The skills and knowledge we gained for delivering high-tech care management helped us provide support for all our members, whether or not they were participating in the study. Tasks we once thought would be ineffective or even impossible without being face-to-face with a member were now doable. Conference calls with providers and community resources were now a part of our everyday service delivery. We were able to complete our jobs and provide assistance and support to all our members even though we had many COVID-related restrictions to navigate.
- Care Manager
Optimal discharge planning: The goal of optimal discharge planning is to reduce hospital readmissions by providing increased care management for a brief time once a member is discharged from inpatient care. Our team used in-person and telephonic modalities for two weeks to engage members in care management, and if needed, an additional two weeks for resource connection. Within this timeframe, our team’s goal was to accomplish as much as possible with each member and then make a warm transfer to appropriate resources, such as a telephonic care team. In the end, staff were able to address most, if not all, of our members’ known or expressed needs thanks to the determination and commitment of both our team members and member participants. Incorporating this distinct type of care management into the study ultimately helped us better understand different facets of care management that are most impactful for our members.
Reflecting on the UPMC Health Plan Community Team’s experience
All in all, the UPMC Health Plan Community Team benefited from our involvement in the Integrated Care Study even though there were challenges to overcome along the way. The skills and knowledge we learned through participation in the study continue to be a vital part of our care management workflows today. Based on study findings, we can use effective components from each integrated care management approach and develop care plans for our members that are individualized, beneficial, and efficient. The outcomes we measured during the study helped to demonstrate the positive impact integrated care can have on members. They also have helped our team see the expansive number of social problems we were able to help address with our members through integrated care management approaches.
The study showed that our team helped address problems such as transportation, housing, food insecurity, access to providers, care coordination, medication adherence, and so much more!
Today, our program is not the same Community Team as it was when the study began—our program and our team have evolved and grown. We are utilizing the skills and knowledge gained through the study, including technology, efficient outreach approaches, better coordination of care with providers, and individualized care management services. It has been a great privilege to be trailblazers in the care management world!
Learn more about the UPMC Health Plan Community Team.
Interested in learning more about the Integrated Care Study? Our final study results will be published in 2025 - until then, stay tuned for the next installment of our Integrated Care Study Blog Series.