In today’s complex healthcare landscape, effective care management requires seamless coordination across multiple disciplines, including care management, utilization management, care coordination, disease management, and population health management. Automated solutions enhance efficiency, but without well-structured workflows, even the most sophisticated technology can fall short of delivering optimal outcomes.
The Role of Care Management Workflows
Automated care management solutions ingest data from a variety of healthcare data sources, including electronic health records (EHRs), claims systems, remote monitoring devices, assessments, and more. This data aggregation provides broad-spectrum visibility across the healthcare continuum, enabling real-time decision-making and proactive interventions. However, to harness this wealth of information effectively, organizations must establish structured, dynamic workflows that ensure:
- Timely Identification of High-Risk Patients – Automated workflows trigger alerts for patients requiring intervention based on predictive analytics and risk stratification models, enabling care teams to prioritize cases and allocate resources efficiently.
- Seamless Care Coordination – Standardized workflows facilitate collaboration between care managers, primary care providers, specialists, and community resources. By automating task assignments and communication, organizations can reduce gaps in care and improve patient outcomes.
- Enhanced Utilization Management – Automated workflows streamline prior authorization, medical necessity reviews, and discharge planning, reducing administrative burden and ensuring compliance with payer requirements while promoting cost-effective care.
- Improved Disease and Population Health Management – Data-driven workflows enable early intervention for chronic disease management and preventive care. By integrating evidence-based guidelines into automated processes, organizations can promote adherence to care plans and mitigate complications.
- Regulatory and Quality Compliance – Automated solutions can incorporate NCQA, HEDIS, and other quality measures into workflows, ensuring adherence to regulatory standards and enhancing performance in value-based care models.
The Value of Elligint Health Helios® Configurability & Automation
Elligint Health Helios is 90% configurable out-of-the-box and provides built-in, intelligent functionality that helps clients automate and streamline care management processes, member prioritization, and even outreach and communications. Our flexible and easy-to-configure workflows and rules allow clients to conduct workflow mapping to identify inefficiencies, ensure compliance with care guidelines, and set up specific criteria and rules that trigger a workflow to automate a specific activity. Clients that have used our automation rules have increased the efficiency of their care management teams by up to 92%.*
Elligint Health Helios offers a wide array of automated capabilities to drive provider and payor efficiency. Examples include:
- Automated messaging
- Automated case noting
- Automated correspondence generation
- Automated case assignment
- Automated referrals
- Automated eligibility checks
- Automated tasking and resolution
- Automated assessment field population
- Automated risk scoring
- Automated service plan population
- Automated care plan or element population
- Automated multi-source data ingestion
- Automated approval
By strategically integrating automated workflows, care teams can transform care management operations, improve patient outcomes, and maximize the value of their technology investments. As the pace of healthcare continues to accelerate, its future depends on finding ways to enhance efficiency, compliance, and patient-centered care.
For more information on using automation to make your care team more efficient, contact your Account Manager today.
*Assumptions
- Based on 160 hours a month (40 hours a week).
- Assumes an average of 60 cases per care manager per month, which is within the recommended monthly caseload (40 – 70) for a care manager at an MCO, per the American Association of Managed Care Nurses (https://www.aamcn.org/guidelines_final%20draft.pdf).
- Represents a limited subset of automated, event-driven actions that occur in Helios every second.
- Assumes manual performance of action would require 1 minute for rules, case notes, risks, and tasks; 5 minutes for referrals; and 10 minutes for care plans. Since many actions involve a review of the patient record, this is prone to human error and limited knowledge.