John Ramsey: Let’s start by reviewing today’s agenda. We’ll be talking about care management, case management, and how the Patagonia Health EHR supports both. In fact, this session could just as easily be called “Care Management and Patagonia Health Beyond the EHR,” since I’ll also touch on where we’re heading in the future.
I’m not a care management expert or a workflow consultant, but my role as a Business Analyst within the Product Management team gives me a broad perspective. I’m part communicator, part planner, and part problem solver.
At Patagonia Health, our product management process includes:
- Engaging with customers and internal stakeholders
- Gathering requirements from various sources
- Analyzing and synthesizing those ideas into solutions
- Prioritizing and managing feature implementation
- Communicating updates internally and externally
Public Health 3.0 and the EHR
Before diving into care and case management, it’s important to connect these topics to Public Health 3.0, a major framework influencing our work as an EHR provider.
Public Health 3.0 is about going beyond simply documenting patient records. It emphasizes:
- Outreach and engagement with the community
- Building connections with external providers
- Achieving full interoperability with other agencies
Our EHR aligns with these principles to help agencies meet their evolving public health goals. It’s not just about tracking cases—it’s about supporting a connected, proactive system of care.
Care Management vs. Case Management
These two terms are often used interchangeably, but they have subtle differences worth understanding.
Definitions and Scope
When people talk about case management, they may refer to a wide variety of responsibilities—sometimes even outside healthcare. A case manager might handle legal aid, financial counseling, or job placement. In other words, the role can be very broad.
In healthcare settings, however, case managers are often focused on specific programs, such as diabetes or asthma management.
Care management, on the other hand, tends to be more integrated and patient-centered. Care managers often work directly with both patients and providers, ensuring coordinated care and smoother transitions across services.
The Triple Aim Connection
The rise of care management parallels the development of the Triple Aim framework, which seeks to:
- Improve the experience of care
- Improve population health
- Reduce healthcare costs
In that sense, care refers to the direct, patient-focused activities, while case refers to documentation and tracking. You might document a “case” in your system, but you’re performing “care management” as you interact with and support the patient.
The Impact of Care Managers
7:50
My first experience with care management came before joining Patagonia Health, when I worked with a community care organization affiliated with Duke Medical Center. They were conducting a study on post-hospital-discharge interventions triggered by ADT (Admission, Discharge, Transfer) feeds.
They tested several approaches:
- Notifying primary care providers when a patient was discharged
- Encouraging patients to follow up with their PCPs
- Sending automated letters
- Notifying care managers
The findings were clear: the only intervention that made a measurable impact was notifying the care manager.
Why? Because care managers act as navigators—or even concierges—within the healthcare system. They understand the system’s complexities and help patients connect with the right resources. Many patients don’t fully understand their care plans or available services. Without guidance, they may delay seeking help, misunderstand medications, or rely on emergency departments unnecessarily.
Care managers fill that gap by:
- Creating and implementing care plans
- Coordinating interventions
- Educating patients and helping them access needed resources
They’re essential for translating complex systems into meaningful, personalized care.
The Care Manager’s Process
11:31
Here’s what a typical care management workflow looks like:
- Referral Intake: Receiving referrals (from hospitals, providers, or self-referrals).
- Screening/Assessment: Identifying needs and risks.
- Enrollment/Referral: Enrolling patients into programs or referring them to community services.
- Tracking: Monitoring progress and ensuring successful connections with external providers.
The specifics vary across states and programs. Some care managers deliver direct services; others act primarily as connectors, educators, or counselors—helping patients access transportation, appointments, or other supports.
EHR Support for Care Management
Caseload Management Tools
Previously, care managers relied on reports to identify active cases. Now, the Caseload Widget brings this information front and center.
The widget allows filtering by:
- Program
- Assigned provider
- Referral status (e.g., open, active)
It remembers these filters, so when you return, your view is ready. You can manage open referrals, update statuses, and use the dashboard as a live task list—showing which patients need follow-ups, assessments, or updates.
For example, when a referral arrives (by fax, call, or self-referral), it’s logged with a service enrollment status of Open Referral and assigned to the appropriate provider. Once eligibility is confirmed, the provider can update the status to Active—moving the patient into the caseload for ongoing care.
This streamlined workflow ensures patients move efficiently from referral to active management.
Program Examples
19:00
Each state and program customizes workflows, but a few examples illustrate how our tools support different approaches.
1. Community Connections
This app, developed for a community health worker hub in Michigan, follows a Pathways-style model based on assessments and interventions.
The workflow includes:
- Initial Referral Form: Captures referral reason, provider info, and acceptance of service.
- Reasons for Referral: Allows multiple needs (e.g., medical, social).
- Pathways Tracking: Connects referrals to Social Determinants of Health (SDoH) such as housing, food access, or transportation.
- Signatures and Assignments: Staff complete and sign off forms, which then appear on assigned dashboards for review.
This tool helps community health workers manage and track interventions efficiently—particularly around social determinants that influence health outcomes.
2. Referral Tracking
Within the Montana Home Visits application, a specialized referral tracking tool was developed to meet grant reporting goals. It doesn’t just track referrals—it measures connection success over time.
Statuses include:
- Ineligible (no follow-up needed)
- Declined
- Open Referral (still in progress)
- Active Relationship (successfully connected)
This helps programs quantify effectiveness, showing how many referrals led to successful connections and how many required multiple attempts. Reports can then analyze patterns—helping agencies understand and improve referral outcomes.
Patient Interventions and Care Plans
Patagonia Health uses the concept of Patient Interventions to help manage care plans and track progress. Originally developed for home visiting programs, it’s now widely used in behavioral health and care management.
Interventions follow a structured model of Problem → Goal → Objective → Intervention, and can be customized for any program.
In practice:
- Care managers can document interventions directly in progress notes.
- Notes link to interventions, allowing ongoing tracking.
- Reports summarize intervention types, duration, and outcomes.
The Path Ahead: Beyond the EHR
42:36
Looking forward, Patagonia Health is expanding its vision beyond the EHR—toward a more connected and interoperable ecosystem.
EHR is about data exchange and collaboration. We’re developing features that allow:
- External Referrals: Community partners or patients can submit referrals that appear directly on the dashboard. Staff can then review, verify, and convert them into patient records.
- Self-Referrals: Similar to our Mass Vaccination app, where patients self-refer for immunizations.
- Outreach and Education: Using enrollment data for mass communication campaigns to educate and engage patients.
- Enhanced Reporting: Improved customization and reporting for interventions, care plans, and outcomes.
- Integrated Planning: Bringing treatment planners directly into treatment plans for easier tracking and updates.
The ultimate goal is to improve population health outcomes, enhance the patient experience, and reduce healthcare costs—all while supporting health departments and agencies in doing more with fewer resources.
Closing
49:58
John Ramsey: Fantastic. I’m really glad we had the opportunity to talk through this today. I hope everyone learned something new about the system—whether it’s a feature you hadn’t used before or insight into where we’re headed with care management tools at Patagonia Health.
