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Streamlining Utilization Management Through Care Collaboration

According to the Centers for Disease Control and Prevention (CDC), there are approximately 139 million emergency department (ED) visits every year in the United States. Some studies show that up to 37 percent of those are non-urgent. For many individuals, such as safety-net populations, the ED serves as the front door to the nation’s complex healthcare system.

With ED physicians serving as the primary decision makers for up to half of all hospital admissions—addressing patterns of high ED utilization is also an important step when it comes to preventing unnecessary hospital admissions and readmissions. Annually, the US spends $41.3 billion on readmissions alone, yet one study of readmitted patients suggests that around one quarter are potentially avoidable.

For payers, effectively identifying members with patterns of high utilization and working to redirect that care to lower-acuity care settings not only saves on care costs, but often leads to better clinical outcomes as well.

CareOregon, a nonprofit that provides health plan services to low-income individuals in Oregon, takes a holistic approach to supporting its member population. Part of providing transitional care for its large population of dual-eligibility members between hospitals and skilled nursing facilities meant a great deal of calling around to hospitals across the state.

To help reduce administrative burden, CareOregon turned to real-time data and care coordination. With the help of technology that fed directly into CareOregon’s utilization management platform, identifying, tracking, and supporting members became less manual, and more automatic. Care coordinators were able to better prioritize their caseload, meaning they could focus on following-up with the most at-risk members first.

Providing timely follow-up and additional support has had a positive impact on the utilization CareOregon was seeing. Since implementing changes, CareOregon has been able to reduce its 30-day hospital readmission rates to just 7-8 percent—saving on care costs and improving member outcomes in the process.

Brittany Eastman
Content Marketing Specialist