Elevating Healthcare Member Engagement for Better Health Outcomes

Today’s health plans face many challenges, including increased competition due to factors including the abundance of options available to beneficiaries, an aging population, rising member expectations, regulatory pressure, and a complex and diverse demographic. One critical way health plans differentiate their efforts to improve care is by providing an exceptional member experience.

However, when engaging members with multiple chronic and complex healthcare conditions— such as many members on Medicaid, Dual Eligible Special Needs Plans (DSNP), or pediatric populations under the Comprehensive Family Life (CFL) program—the challenges become even more formidable.

Challenges to Member Engagement for Complex Populations and Chronic Conditions

The clinical needs of Medicaid populations with chronic illnesses are diverse and often require coordination across multiple specialties. For pediatric populations, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings are required for early identification of health issues. Care managers must fulfill the needs of providers, staff, families, and regulations while also overcoming operational hurdles that create inefficiencies and high administrative loads. To deliver compassionate and comprehensive care, care managers require more advanced systems to manage larger caseloads more effectively, reduce frustration, and streamline their vital role in enhancing care quality.

Member communication

Effective communication is crucial for engaging members in their care plans regardless of their situation. Yet, ensuring a smooth experience across multiple channels—from in-person visits to digital platforms—can take time and effort, particularly with high-risk populations. Integrating communication channels, accounting for member preferences, and making the care experience easier to navigate requires a thorough understanding of member resources, behaviors, and preferences, as well as advanced technology.

Social Determinants of Health

Social Determinants of Health (SDOH) significantly impact members living with multiple chronic illnesses. Effective member engagement for complex populations goes beyond traditional clinical interventions and requires partnerships with community organizations and a robust data-sharing infrastructure to address SDOH like housing instability, food insecurity, and education.

Regulatory Reporting

Government programs have strict regulatory reporting requirements that care managers must follow. These regulations continuously change, and updates come at an increasing frequency while the penalties for non-compliance get steeper. As federal and state agencies push for greater transparency and interoperability, care managers must adapt to these administrative changes. This can distract from their focus on care, especially when dealing with legacy systems.

Disparate Technology Systems

Many member engagement solutions operate in silos, making it difficult to access a unified view of members to coordinate care, communicate effectively, and tackle administrative tasks. Interoperability between systems is critical to providing coordinated care and a personalized and effective member experience.

The complexity of care, integration of social support, and the barriers to communication for the populations in greatest need require a nuanced approach to service delivery and the technology that supports it.

Digital Care Management Goes Beyond Just Communication

Digital care management is an innovative approach to healthcare that transcends traditional communication methods, offering more engaging, informative, and proactive interactions that are crucial to member engagement of complex populations. At its core, digital care management solutions offer services including:

• Health education articles tailored to the individual’s clinical needs and based on specific care programs to help members understand and manage their health conditions.
• Interactive assessments that enable real-time data sharing about a member’s health status, keeping care managers informed and allowing them to be proactive in their care strategies.
• Encouragements and motivational messages that help members become advocates for their health and foster improvement through ongoing discussions.
• Automated reminders that help care managers and members stay on track with critical activities and milestones, ensuring that important care management tasks are not overlooked.
• Omnichannel features such as chat and secure text messaging that facilitate real-time, bidirectional communication, making it easier for members to connect with their care teams and vice versa.
• A dashboard view of each member that allows a care manager to have a unified view of their situation, interactions, and health journey.

Digital care management, as delivered by the HealthEdge® Wellframe® member experience platform, represents a shift from episodic, intermittent support to a continuous, holistic care model. It leverages technology to extend the reach of care teams, enabling them to engage more fully with high-risk members and significantly impact engagement:

• With the Wellframe platform, members average 258 touchpoints per month with their care teams.
• Wellframe drives significant increases in Medicaid member engagement without increasing staff. A HealthEdge analysis of one health plan showed a rise from 3 touchpoints per case to nearly 200, resulting in 14 days engaged per month.
• With Medicare members, another analysis showed that care managers increased total touchpoints from 3 to nearly 500, resulting in 15 days engaged per month for six months.

With digital care management, members are empowered to take an active role in their health journey, supported by the tools and resources necessary for effective self-management and improved outcomes.

Care-Wellframe: Integrating Engagement and Care

Care-Wellframe is an integrated solution that combines HealthEdge’s premier care management platform, GuidingCare®, with Wellframe. The solution transforms how health plans approach digital care management, removing barriers for the most complex use cases with one solution rather than trying to solve care and experience with separate solutions.

This packaged integration makes the following possible:

• Seamless data sharing between GuidingCare and Wellframe that eliminates redundant data entry and the inefficiency of using separate systems.
• Instant access for both care managers and members to clinical education materials, benefit plan details, and community resources related to Social Determinants of Health (SDOH) in one system for quick, relevant referrals.
• Prioritization, through alerts and insights, of members who most urgently require outreach, streamlining the care management process and personalizing content to their needs.
• Tracking care plan adherence directly from the member’s profile, and an online chat feature accessible through the interface.
• Omnichannel communication which allows care teams to reach members through their preferred channels.

With Care-Wellframe, members benefit from personalized interactions and are supported by trusted care managers who empower them to make informed health decisions. Digital care management enables care managers to improve clinical outcomes, engage meaningfully with members, and reduce administrative tasks—especially when dealing with high-risk populations such as pediatrics or those covered by Medicaid or DSNP.

Next-Generation HealthCare Member Engagement

To effectively manage member experience for populations with complex healthcare needs and enrolled in government programs, it is essential to have a comprehensive approach that combines integrated, next-generation technologies with compassionate, person-centered care.

Health plans must efficiently scale care management teams to support more complex use cases. Streamlined member engagement integrated with care management leads to better health outcomes, membership growth, higher member satisfaction, and better Star ratings. With Care-Wellframe, health plans can meet these vulnerable groups’ clinical, social, and regulatory needs while fostering continuous engagement and support.

Learn more about how your organization can improve member engagement and care management with key insights from our 2024 Consumer Survey.