Care managers are often at a loss when dealing with high-risk individuals who have compounding problems, including multiple chronic diseases, behavioral health co-morbidity and social issues, such as homelessness. They frequent emergency rooms, have high rates of inpatient readmission, and are unable to adhere to a care provider’s treatment plan. Beacon takes a three-pronged approach to high-risk care management that includes informatic identification, community-based engagement, and peer-based social support.
The graph below illustrates how Beacon used a team-based approach to engage high-risk members for one of Beacon’s clients.
Beacon engages high risk Members using a Team based approach
As demonstrated in the graph below, this approach has not only decreased
the overall costs of care, but has also improved health outcomes.
Integrated BH, physical, and social case management lowers costs
Source: WCAP
Year Published: 2010
Metrics
| Assessment | Baseline | 6 months post | P vale |
| IMCAG Mean | 28.5 | 25.6 | .0014 |
| PAM Median | 47.4 | 52.9 | .07 |
| SF12P Mean | 33.5 | 35.8 | .02 |