Case Study

Healthcare major transitions to value-based care with a digitally powered operating model

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A leading US healthcare system


Business need addressed:

  • Reimagine care management processes, where were modeled for episodic care and fragmented in nature
  • Improve collaboration between care entities, consistency of patient management, and accuracy of patient data capture and reporting
  • Increase focus on the overall care continuum to drive population health outcomes

Genpact solution
Using a Lean DigitalSM approach, the healthcare organization implemented:

  • Process transformation, moving non-specialized tasks to a custom support center
  • Standardized documentation and patient hand-off protocols, enabling a one-stop view of important patient information
  • Unified access to healthcare records and improved data visibility via master data management, patient analytics, and standardized documentation and reporting
  • Instant alerts for designated patient profiles, and real-time case manager identification functionality

Business impact:

  • Improved patient care and population health to enhance patient experience and patient satisfaction
  • Reduced re-admission rates for patients under federally mandated population health initiatives, driving down costs and improving performance under the value-based care model
  • $3.2 million reduction in dollars at risk (denials and downgrades) annually improves revenue realization
  • Targeted technology interventions set the stage for an agile future state of operations covering end-to-end disease management programs, predictive analytics, and integrated palliative and behavioral health programs

A leading US healthcare organization looking to transform into a value-based payment-driven accountable care organization (ACO) model was hindered by fragmented case management processes, poor collaboration between care entities, inconsistent patient management workflows, and nonstandard data collection and reporting, leading to poor patient experience, higher costs, and decreased revenue. Using a Lean DigitalSM approach, the organization reimagined front-, middle-, and back-office processes to enable an integrated view of care. Through specialized task allocation, revised operating procedures, and targeted technology interventions the provider reduced re-admission rates, improved customer satisfaction, enhanced growth, and reduced costs.

Business challenge

The healthcare organization had to design, implement, and manage a patient-centric and integrated care management model to ensure survival and success of the value-based payment ACO model. Their existing case management model focused on episodic care rather than each patient’s unique healthcare history and needs. This was due to fragmented communication between inpatient and outpatient care management teams, inconsistent patient management workflow, and unclear roles and responsibilities of care-giving, administrative and support teams. They were also hindered by poor care coordination, resulting in suboptimal healthcare outcomes, patient experience, and costs.

Genpact solution

A team of domain and operations experts deployed a combination of design thinking and lean practices such as “day-in-life” studies of case managers and other stakeholders, peer benchmarking through site visits to similar health systems, and cross-functional kaizen workouts to identify the sources of value (and waste) and define a future-state operating model aligned to achieve outcomes relevant to the new value-based payment business model, rather than the old fee-for-service business model. A new organizational design was implemented with redefined roles and optimized resource allocation. The change was supported via new standard operating procedures, restructured roles, more focused use of technology and analytics, and robust change management, including training and communication for case managers, nursing staff, and physicians. The following initiatives helped the ACO implement a patient- and primary care-centric care management model:

Reimagining front-, middle-, and back-office operations by:
Creating capacity for case managers to focus on patients 

Decoupled complex tasks being performed by case managers and allocated these to specialized teams:

  • Admissions and denials management team to manage relationships with payers, appeals, and denials
  • Case management roles from hospital units, social workers and nurse clinicians was transitioned to dedicated case managers assigned to each hospital unit

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  • Support center operations like transport process, dialysis, etc., were optimized, freeing up resources to take on simple tasks from case managers (e.g., treatment authorizations for wounds, no primary care practice (PCP) setup, etc.)

Aligning care managers to PCP for better care coordination and resource utilization
A scientifically designed process was implemented for effective coordination between hospital, primary care, and community care managers. Scientific stratification of patients based on past history, care needs, and risk profile was used to direct them to appropriate care management interventions, which addressed re-admissions, lifestyle diseases such as diabetes, and advanced care planning.

Enabling the transition towards population health management
Standardized documentation and patient hand-off protocols enabled a one-stop view of important patient information. Specialized case management teams and processes helped coordination of hospital case management with other community care stakeholders (e.g., extended care and primary care facilities), enabling a seamless transition for patients going home or moving to alternate care facilities.

Focused use of technology and analytics to support reimagined operations
Technology infrastructure was revamped to aid collaboration across multiuser, multidevice environments, enable better coordination between stakeholders, and improve access to healthcare records (EPIC) across designated user profiles (case managers, social work, and nurse clinicians). Data visibility across the care continuum was enhanced through master data management, dashboards, and standardized documentation and reporting to ensure a single view of critical patient information across the care continuum. Case management and reporting for specific care types (such as ambulatory care and acute care) was also enhanced through analytics to drive real-time data availability, transparency, and access, along with e-handoffs for case management documentation. Additional functionalities such as instant alerts for ambulatory case managers and active-inactive case manager identification functionalities were also developed.

Business impact

Improved patient care and population health
Better collaboration across the care continuum helped in integrated care delivery, increasing the focus on high-utilization patients, improving post-discharge transition to primary care practices, and boosting patient experience and patient satisfaction.

Better financial performance
A $3.2 million reduction in dollars at risk (denials and downgrades) led to better revenue realization, while reducing the organization’s overall 30-day re-admission rate (measured annually)—and reducing that rate by 2% for Medicare Shared Savings Program (MSSP) patients—enabled further cost savings and better margins through value-based care shared savings.

Future-ready agile operating model
Targeted technology interventions enhanced collaboration within and across the organization, ensured robust master data, and enhanced insights into operations for better decision-making. Improved collaboration across the care continuum enabled the organization to move from episodic care to a cross-continuum care model, and resulted in ongoing population health initiatives, such as integrated disease management programs, predictive analytics that interfaces with EMRs, and integrated palliative and behavioral health programs.

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