Triumph: Launch New Enhanced Care Management Service
Enhanced Care Management for Seniors with One or More Chronic Conditions to Improve Health Behaviors and Reduce Hospital Readmissions
“CareThree helped us develop, launch and operate our innovative ECM health coaching program. We focus on social care and interact with the patient’s care team. The Care3 tech platform gives us the ability to do both.”
Overview
On Lok Connected Care is a coach-based enhanced care management program developed and operated by On Lok, Inc. in partnership with CareThree. Connected Care provides services that aim to bring meaningful behavior change to at-risk seniors across clinical, functional, social and emotional domains over the course of one year.
Primary measures are re-hospitalizations and self-reported overall health and well-being.
Results
On Lok Connected Care ECM program performed vastly better than the industry benchmark for 30 and 90 day readmissions among at-risk seniors
30 Day Rate: 67% reduction
90 Day Rate: 65% reduction
Derived from the Short Form 8 (SF-8) survey, On Lok measured the following two questions as most relevant for program success:
Overall, how would you rate your health during the past 4 weeks?
During the past 4 weeks, how much have you been bothered by emotional problems (such as feeling anxious, depressed or irritable)?
Participants were asked to complete the survey at the beginning of the program (Survey 1) and after six (6) months in the program (Survey 2) to measure impact.
Question 1 Impact
Question 2 Impact
Lasting Impact
On Lok Connected Care for Enhanced Care Management delivered vastly improved readmissions outcomes versus NEJM benchmarks:
83% of participants who took two (2) Overall Health & Emotional assessment reported positive changes
Financial issues drive health decisions among active participants. Medi-Cal enrollment is a key opportunity
The Program is timely based on the amount of help (SDOH) needed as reported by active participants
This report is intended to:
Assess the opportunity to build a scalable ECM service through innvoative structures and technology deployment
Provide data, context, and/or actionable insights about Coach Time, care activities, and survey responses
Paint a longitudinal picture of the changes in participant experiences in the Connected Care program