By Natasha VanWright, RN, MBA, MS, MA, CCM and Ramon Jacobs-Shaw, MD, MPA
A 60-year-old woman living with a multitude of chronic conditions, Patricia felt weighed down by guilt. She was convinced she’d become a burden to her daughter, on whom she relied to navigate her various medical needs.
Patricia was on dialysis, and a kidney transplant was unavoidable. Her future, she was certain, was trending downward.
Unsurprisingly, when Belong Health’s care management team first met Patricia, we found her hesitant to engage with a personal health plan. After all, she had reminded us, a care manager was already helping her with dialysis. What more could be done?
Patricia had unknowingly been sitting on numerous untapped benefits for which she, as a dual-eligible member, qualified.
One such benefit was access to her very own care management team — including a registered nurse (RN), a licensed clinical social worker (LCSW), a community health worker (CHW), and pharmacist. Together, these experts began answering questions about Patricia’s health, helped get her the resources she needed, and worked closely with her in setting achievable personal health and wellness goals for the long term.
Just as important: Patricia’s care management team members understood the hopelessness and fear she’d begun to feel about her future. Together, they reviewed her medication and connected her with a trusted behavioral health specialist.
With the expertise of Belong’s Chief Clinical Officer at the ready, they also directed Patricia and her daughter to a primary care provider for comprehensive discussion of a long-term treatment plan.
And, in the spirit of collaboration, they alerted her provider that Patricia had been receiving dialysis for a year — a detail she had not previously shared with her doctor.
Thanks to the LCSW on her personal care team, Patricia was even set up with home health services — resources that enabled her and her daughter to explore additional caregiver support options without stress. Together, mother and daughter benefited from the guidance of a Consumer Directed Personal Assistance (CDPA) agency, whose experts assisted in the submission of all necessary paperwork.
At its best, effective care management for patients with complex needs forges invaluable relationships with physician networks. It simplifies and eases each member’s unique healthcare journey.
That’s exactly the kind of care management Belong Health is designed to facilitate.
“This program and the care management team really knew how to help me,” Patricia later told us. “I’m glad you would be there for me.”
Belong Health is proud to offer a differentiated care management experience that consistently draws the very best from members, providers, and from our own care team. Here are seven ways our care management offers better outcomes and experience:
- We Value Long-Term Relationships
The best care management is long-term and relationship-based — which is why every Belong Health member gets a call from our care management team and enjoys a single point of contact throughout their experience with us.
For Patricia, this relationship-nurturing process meant underscoring the difference between her dialysis care manager and her whole-health care manager, and then empowering them both to do their best work.
- We Champion Data-Driven Care Management
With an eye towards both big-picture comprehension and intimate person-to-person engagement, we review typical claims data and evaluate who is pushing those claims. We factor in Health Exchange Data, and other data systems, in the creation of an elaborate portrait of every member’s social and health needs. And although the data is delivered from many data systems, Belong’s technology can quickly digest the data delivering it in a timely and actionable way.
Simultaneously, we regularly consider demographics — including income, geography, and race — when determining the best care management plan. Throughout, we are driven by an awareness that healthcare is a deeply individualized and deeply felt experience.
- We Offer a Field-Based Approach
Our field-based, team approach to care equips each member with a personalized “pod” that includes a nurse, a social worker, a community health worker, a pharmacist, and a medical director — all of whom work together to develop a tailored plan for each member.
After a personalized “pod” meets with a low-risk member, our experts may determine outreach to that member is needed only every 90 days and could easily be done by a community health worker alone. This tailored process not only meets each member’s needs, it shifts higher-cost resources, such as nurses, towards high-needs members and reduces financial waste.
In Patricia’s case, such laser-focused and personalized care meant her medical director connected with her primary care provider while, simultaneously, her social worker connected her with home health services and with individualized support for her and her family.
- We Experience Robust Training
Each member of every care management team attends an eight-week training in their “pod” format, shoulder-to-shoulder with their interdisciplinary colleagues. Together, they are educated in a fuller understanding of social determinants of health and are steeped in an awareness of culturally competent care.
Each training incorporates behavioral design to drive impact and engagement. Throughout these sessions, pod members review case studies and focus on iteratively gaining member insights that help point the way to best care practices.
- We Enjoy Interdisciplinary Care Rounds
As each pod of experts meets on a regular basis to discuss their members’ health, we welcome members, their care support, and their primary care providers to join in on those transparent discussions.
After every pod meeting, discussions are asynchronously reported out so primary care providers who may not have been able to attend can follow their patient’s progress.
- We Reach Behavioral Science-Based Conclusions
Everything we do at Belong — from care management to hiring to member outreach — is rooted in behavioral design, a problem-solving methodology that directly confronts those psychological biases that can impede best care practices.
We also embrace a Positive Assessment approach to care management. Instead of asking, “what’s wrong?” our care management specialists approach each member conversation with, “what brings you joy?” and “what is going well in your life?”
Positive Assessment helped us recognize one of the biggest obstacles to Patricia’s health was the self-imposed guilt she felt for believing herself to be a “burden” to her family. Only after addressing that deeply held concern were we able to help Patricia feel confident in managing her own health with a team of experts.
- We Strengthen Disaster and Emergency Preparedness
We are proud to guide members in the development of personalized plans in case of emergencies. Do they need electricity for ventilators? Do they need someone to help them prepare food?
Together, we create a plan that will keep each member safe in those sudden moments when water or power may be unavailable. We also check in with members, during emergencies, to ensure those plans are working. The result often reduces stress on our members and care teams alike.
Taken as a whole, Belong Health’s unique approach to care management means personalized peace of mind is more possible than ever for our members. Whether their concerns are long-term or short-term, we consistently connect them with services — such as safe housing and free and reduced food options — that elevate their health, safety, and self-confidence.
This is possible only by connecting each member with someone who prioritizes their health as much as they themselves do.
That’s the core of our mission. That’s what ultimately sets our work apart.