Value-based care marks a paradigm shift in the healthcare industry, focusing on patient outcomes and cost effectiveness. Healthcare providers believe that AI-enabled care management is crucial to delivering value-based care (VBC) in the evolving healthcare industry. Adopting value-based care aligns the healthcare providers’ goals with patient health. This approach not only improves patient care quality but also reduces extended hospital stays and costly emergency services.

Care management still lacks data-driven insights, as it cannot benefit of the data from the medical records. Providers and payers can drive meaningful improvements in patient outcomes, reduce unnecessary healthcare utilization, and ultimately achieve the goals of value-based care by investing in AI. AI has the potential to convert healthcare data like medical notes into insights to provide effective care management.

What is AI-Enabled Care Management

An AI-enabled care management approach utilizes artificial intelligence algorithms to analyze patient data, identify care gaps, and facilitate communication between healthcare providers. It can integrate with electronic health records (EHRs) and other healthcare systems to collect and process relevant information in real-time. The AI algorithms can then generate personalized care plans, monitor patient progress, and make recommendations to optimize care coordination.

AI technologies can contribute to care management by:

• Automating administrative tasks and improved care coordination
• Identification of high-risk patients by predictive risk modeling
• Chronic pain management
• Vast healthcare data sets (Medical images, clinical notes, effective treatment plans, managing healthcare services efficiently)
• Personalized patient care planning
• Preventive care

Why is AI-Enabled Care Management Crucial for Payers and Providers?

AI-enabled care management is important for payers and providers to improve the following:

• Efficiency: AI manages administrative tasks, from identifying patient’s health conditions, scheduling appointments to processing insurance claims, allowing healthcare professionals to focus on what they do best—caring for patients.
• Accuracy: AI analyzes vast datasets to help in diagnosing diseases more accurately and prescribing the most effective treatments, reducing the chances of human error.
• Patient Outcomes: AI’s predictive capabilities can help in early detection of diseases for at-risk patients, improving their chances of recovery and quality of life.

Organizational Maturity and Readiness for AI

While integrating AI into care management, it is imperative to stay ahead of several factors. Organizational maturity is the first and foremost step when planning to use AI in care management. Start small with lower-risk use cases and scale up as organizational maturity increases. The next step is to ensure if the organization has the readiness to integrate AI with the existing infrastructure and workflows. Payers and providers require identification of their current pain points within their organization. Select the top areas for better ROI on AI that hone business and clinical outcomes. This helps align with the organization’s existing practices, and effective decision-making.

How AI can Enhance Patient Care and Operational Efficiency

AI-enabled care management can enhance patient care by providing personalized treatment plans and monitoring patients remotely, it can improve operational efficiency by automating administrative tasks and optimizing resource allocation.

• Predictive Risk Modeling: A risk analysis to identify high risk patients for care management programs. These are based on their chances of developing chronic diseases, becoming high-cost claimants in future or worsening their health condition.¹

• Auto Compose Clinical Messages: AI-powered language models can be integrated into care management workflows to assist medical practitioners in composing responses to patient messages.

• Patient Prioritization Modelling: AI can be leveraged to rank and prioritize patients’ outreach, thus improving efficiency for the care management teams.

• Automate Healthcare Outbound Consumer Messaging: AI technology can be used to automate the generation of patient messages including considering their preferred language, clinical records, and the SDoHs. This reduces the burden on care managers and increases patient satisfaction.

• AI-generated Next Best Action: An AI algorithm can integrate and analyze a wide range of data, and suggest personalized next best action for patients with multiple diseases and health conditions.

• Automate Patient Care Navigation: An assistant to support patients with care navigation (e.g. scheduling appointment, insurance eligibility, etc.) to increase efficiency and improve member satisfaction.

• Auto Generated Assessments, Patient Education and Clinical Summaries: Auto generated personalized care management program assessments, patient educational materials and visit summaries to reduce the burden on care providers.

• Auto Generate Benefits Summaries: AI can be leveraged to auto generate personalized summaries of benefit plans and certificates of coverage to increase member satisfaction.

• Augment Data Analysis and Interpretation: AI can be leveraged for convenience of data preparation, report generation and analysis of end users.

The integration of AI-enabled technologies and care management holds great potential to improve healthcare delivery, and patient outcomes. As care management is a crucial part of the VBC programs, the organizational maturity and readiness for AI is one of the most important success factors when implementing AI in care management.

Persivia brings an AI-powered, end-to-end integrated platform, CareSpace®, nurtured over a period of 15 years to revolutionize care delivery processes. CareSpace®’s Care Management capability is built upon a foundation of AI-driven clinical and financial insights, as well as workflow automation. With a growing library of over 200 clinical programs, CareSpace® provides highly specific and detailed Patient Specific Care Pathways, ensuring tailored care for each individual.

It begins with aggregating patient data and enriching it using advanced AI technology. CareSpace® then utilizes this enriched data for risk stratification, automating workflows, and engaging patients effectively.

At the core of CareSpace® is Soliton AI, which analyzes patients’ longitudinal medical records in real time. This analysis enables the platform to generate configurable clinical care alerts, conduct intelligent assessments, and automatically generate care plans. Care managers benefit from access to a comprehensive clinical record of patients across all available data sources, empowering them to make informed decisions.

Moreover, CareSpace® automates program eligibility for various initiatives such as Chronic Care Management, TCM, and AWV. This automation eliminates the need for manual patient record reviews, streamlining the process and improving efficiency. Additionally, the platform offers seamless integration with over 300 home devices, allowing real-time data feed directly into the system. This data is then analyzed to identify potential care gaps, further enhancing patient care.

Gartner has recognized Persivia for its AI-enabled solution within CareSpace® Care Management. Download your complimentary copy now to discover how AI embedded within the system can transform your care management processes and drive better patient outcomes.

Gartner