Enabling Precision Care Management

See how it works in this quick video

Proven Results: One Plan’s Story

Cyft improved a care management team’s outreach accuracy by 220% by predicting those members most likely to have a preventable admission. This included identifying members with no prior admissions – a population typically ignored by traditional risk scores (e.g., LACE). 

Watch the Beacon Health Options webinar.

Target Interventions by Potential Impact

Identifying members for interventions is the foundation of every care management program. Cyft takes this quite a bit further by not just identifying high-risk members (though we do that very well too), but rather by identifying members that care managers can positively impact by using all of your data, including free text, in its native format.

The Cyft Impact FactorTM provides an intuitive understanding of the positive impact that each intervention could have on each member. This enables care managers to maximize stay focused on providing interventions with high predicted ROI.

Match Individuals to Programs they are Most Likely to Benefit From

Care managers are more effective when they start each day with an understanding of the specific interventions they should deliver to each person.

Falls Prevention

¼ of Americans 65 or older fall each year, leading to 2.8 million injuries treated in EDs annually.1

Many falls can be easily prevented with better footwear, changing furniture layouts, keeping walking aid and glasses nearby, and appropriate reorientation strategies.2

Polypharmacy Review

Nearly 50% of older adults take one or more medications that are not medically necessary, with a high risk of Adverse Drug Events (ADEs).   33%  of ADEs lead to hospitalization in patients 75 yrs. and older.3

Approximately 50% of ADEs are preventable. 4

Nutrition Education

Unhealthy diet contributes to approximately 678,000 deaths each year in the U.S.5

Nutrition education can lead to healthier food choices, even in 60-80 year olds.6

Substance Abuse Counseling

~10% of American adults use illicit drugs7, and ~25% of chronic pain sufferers misuse opioids.8

Effective programs help manage addiction throughout life.9

Behavioral Health

Nearly 1/5th of adults have behavioral health issues.10

Case management of mental health services improves outcomes.11

Social Determinants

Social determinants underlie health status and outcomes.12

Many evidence-based interventions are being designed to promote health in the community.13

Care Coordination

Coordinating quality care is a major challenge for people with multiple chronic conditions.14

Better coordination can reduce costs and improve outcomes.15

Chronic Disease Management

Many effective care management programs have been designed around chronic diseases such as diabetes16, COPD17, etc.

Chronic disease management has been shown to significantly improve outcomes.16,17

Work Within Existing Workflows

Integrating within existing processes is critical to decreasing the burden on care managers. From a care manager’s viewpoint, they are provided with additional insight about their population and the specific interventions that are likely to benefit their patients within their existing care management systems and workflows. This ensures care managers have a single system to reference at the start of each day.

Continuously Improve with Real-Time Feedback

Care Managers must see their results to keep improving. With Cyft, care managers are able to see the people targeted that Cyft identified to impact, what activity was done, engagement, and the clinical and financial results. This accelerates continuous improvement by providing real-time insights to the team and senior management.

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References

  1. “Fall Prevention Facts.” National Council on Aging https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/
  2. “Preventing Falls in the Geriatric Population” Perm J. 2013 Fall; 17(4): 37–39.
  3. “Clinical consequences of polypharmacy in elderly.” Maher R. L., Hanlon J., Hajjar E.R. Expert Opinion on Drug Safety 2015., 13(1), 57-65
  4. “Association between acute geriatric syndromes and medication-related hospital admissions.” – Drugs Aging. 2012 Aug 1;29(8):691-9. doi: 10.2165/11632510-000000000-00000.
  5. “The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.”JAMA. 2013 Aug 14;310(6):591-608. doi: 10.1001/jama.2013.13805.
  6. “Supplemental Nutrition Assistance Program Education and Evaluation Study (Wave II)” 16 Aug. 2016, https://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-education-and-evaluation-study-wave-ii
  7. “DrugFacts: Nationwide Trends | National Institute on Drug Abuse (NIDA).” 25 Jun. 2015, https://www.drugabuse.gov/publications/drugfacts/nationwide-trends
  8. “Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.” Pain. 2015 Apr;156(4):569-76. doi: 10.1097/01.j.pain.0000460357.01998.f1.
  9. “The Effectiveness of Drug Abuse Treatment – Princeton University.”https://www.princeton.edu/~ota/disk2/1990/9041/904106.PDF
  10. NIMH » Any Mental Illness (AMI) Among U.S. Adults.” https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml
  11. “A Meta-Analysis of the Effectiveness of Mental Health Case Management Over 20 Years” http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.51.11.1410
  12. “Social Determinants of Health” – https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
  13. “The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model.” –Hosp Q. 2003;7(1):73-82.
  14. “Multimorbidity’s many challenges” –BMJ. 2007 May 19; 334(7602): 1016–1017.
  15. “Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans Under Financial Alignment Initiative” 3 Mar. 2017, https://innovation.cms.gov/Files/reports/fai-carecoordination-issuebrief.pdf
  16. “Effectiveness of disease-management programs for improving diabetes care: a meta-analysis”- CMAJ. 2011 Feb 8; 183(2): E115–E127.
  17. “Effectiveness of chronic obstructive pulmonary disease-management programs: systematic review and meta-analysis” Am J Med. 2008 May;121(5):433-443.e4. doi: 10.1016/j.amjmed.2008.02.009.