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A model to manage capitated risk

J K Moss1, K Steiner, K Mahnke

  • 1Patient Care Services and Performance Improvement, Highland Park Hospital, Highland Park, IL, USA.

Nursing Economic$
|May 21, 1998
PubMed
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Increasing enrollment in Medicare Health Maintenance Organizations (HMOs) necessitates new care delivery strategies. Integrated care management, focusing on wellness and prevention, improves patient outcomes and financial results.

Area of Science:

  • Health Services Research
  • Healthcare Management
  • Geriatric Care

Background:

  • Rising enrollment in Medicare Health Maintenance Organizations (HMOs) presents challenges for healthcare providers.
  • Traditional episodic care models are insufficient for managing the health needs of Medicare enrollees.

Purpose of the Study:

  • To outline strategies for healthcare providers to adapt care delivery systems to increasing Medicare HMO enrollment.
  • To describe the components of an integrated care management system for Medicare enrollees.

Main Methods:

  • Implementation of key risk management strategies: health risk appraisals, proactive case management, disease management, provider education, and inpatient physician managers.
  • Formation of a multidisciplinary health care team (physician inpatient manager, nurse case manager, geriatric clinical nurse specialist, social worker).

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  • Development of a quality management plan to track patient outcomes and quality indicators.

    • Main Results:

    • An integrated care management system requires a collaborative team approach.
    • A focus on wellness promotion and illness prevention signifies a shift from episodic care.
    • The new model has the potential to yield positive financial outcomes.

    Conclusions:

    • Healthcare providers must develop new care delivery strategies to manage increasing Medicare HMO enrollment.
    • Integrated, team-based care management focused on wellness and prevention is essential.
    • Quality management plans are crucial for monitoring patient outcomes and ensuring system effectiveness.