Introducing Salesforce Health Cloud for utilization management

Introducing Salesforce Health Cloud for utilization management

by Paul B. Stevenson, MPA, CPA

Nearly 64 percent of executives say that care coordination is a barrier to health and wellbeing in their communities. Would you agree? With inefficient referral management and ever-growing consumer demand for coordinated treatment plans, collaboration in care and utilization management is more crucial than ever.

Introducing Salesforce Health Cloud for utilization management. The Health Cloud streamlines utilization management processes so that healthcare providers and payers can collaborate seamlessly on care coordination. It helps provide patients with the right care in the right place at the right time. It also makes it easy for healthcare providers to submit care requests for pre-authorization. Utilization management and care coordination pose some challenges, but Salesforce Health Cloud helps you offer personalized and streamlined care with optimal patient outcomes.

 

The challenge of utilization management and care coordination

It may sound obvious, but a recent study confirmed it: fragmented care coordination makes healthcare more complex for patients, and this complexity leads to further coordination challenges. It’s a cycle, and it’s especially dangerous for high-risk individuals like senior, stroke, diabetes, or heart disease patients.

It’s a challenge for nurses, doctors, and other health professionals who handle the coordination of this care to gather and review all the information they need to make decisions. The problem is that information may be scattered among multiple systems if a health plan has grown with mergers in the past. Or medical groups, IPAs, and ACOs might need to gather the information from numerous Electronic Health Records (EHR) systems operated by the physician practices and hospitals who are members. Data aggregation into meaningful information is a nightmare in many instances.

The data is there, the ability to aggregate is there, but how do you integrate all of these data sources without tremendous cost and effort? While HL-7 medical data interface simplifies the process, it still requires a high-productivity environment to aggregate the data and make it useful with tools to allow easy communication, situational assessment, and actionable, measurable outcomes.

 

What is needed

In spite of these challenges, healthcare payers such as Health Plans or Medical Groups, Independent Physician Associations (IPA), or Accountable Care Organizations (ACO) with risk contracts need tools to manage the cost of high-risk cases. They need a single user interface that can aggregate information from multiple sources and present it as a single body of information. This would allow these medical professionals to reap a bounty of increased productivity.

They need automation to help them increase their effectiveness. Automation allows healthcare payers to communicate with providers, patients, and caregivers. It also helps them easily assess the patient case with tools like a patient card that presents vital information to their specialty, and a timeline of patient events would increase their effectiveness.

It sounds like a tall order, but Salesforce Health Cloud is up to the challenge. Using state-of-the-art integration tools like Mulesoft, integrating the data from different systems into your health cloud is cost-effective. Many pre-built adaptors are available for popular EHR systems, which can jump-start the integration process. Once the data is available on the health cloud, your medical professionals can focus on their work without endlessly searching for bits of information.

Salesforce Health Cloud for utilization management is the solution. And here’s why:

 

Personalized and appropriate care at scale

With the Health Cloud, you can create and customize new care request types. Whether it’s admissions, appeals, prescription drug requests, service requests, or any other type of care request. Then providers and administrative staff can manage these care requests, review their statuses, and create and submit new requests. The ability to review and manage care requests makes requests processing more transparent and gets patients the most appropriate care faster.

Salesforce Health Cloud for Utilization Management also provides new standard objects to support a customizable set of requests:

  • Prescription drug pre-authorization requests
  • Service pre-authorization requests
  • Admission cases
  • Concurrent (continued stay) reviews
  • Appeals
  • Complaints and grievances

 

Streamlined care

According to HIPPA Journal, “Between 2009 and 2018 there have been 2,546 healthcare data breaches involving more than 500 records [in the United States]. Those breaches have resulted in the theft/exposure of 189,945,874 healthcare records.”

Clearly, coordination among healthcare providers is something we need to work on! The Health Cloud can help. The Health Cloud streamlines care requests, including admissions, appeals, and prior authorizations, through guided and measurable workflows.

Directly in the Lightning App Builder, admins can reference open cases and review the status of each care request. It’s convenient to view all the details and relevant supporting information for the care request on one single console. To keep everyone on the same page, intake specialists and clinical team members can collaborate around care requests. This streamlines the decision-making process and ensures that the decisions being made are optimal for the patient.

 

Optimal patient outcomes

Health System Tracker found that “On average, other wealthy countries spend half as much per person on healthcare than the U.S.” That is why Health Cloud’s payer capabilities are so important. These help payers contain medical costs, which in turn helps patients have a better healthcare experience. And the utilization management capability helps you evaluate the medical necessity of care and its administration, which also improves patient outcomes.

 

Salesforce Health Cloud for utilization management helps you deliver personalized and appropriate care at scale, streamlines care, and helps you achieve optimal patient outcomes. Utilization management and care coordination do pose challenges, but Salesforce Health Cloud helps you overcome those challenges with ease.

 

Paul StevensonPaul B. Stevenson, MPA, CPA, is Simplus’ Subject Matter Expert in HLS CRM Strategy. An expert with deep CRM experience in healthcare, telecom, distribution, and financial segments, Paul is a consultant who drives CRM innovations to clear a path for growth in revenue and operational efficiency. He has hands-on experience in developing, marketing, and selling CRM Apps and is a proven project leader with skills to lead CRM integrations with payer, provider, telecom, and proprietary operational and financial information systems.

paul.stevenson@simplus.com