Proactive ER diversion
saves $3.25 Million

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Case In Point

A Health Maintenance Organization (HMO) partnered with Carenet to provide its Medicaid members with better healthcare access and care coordination to improve health outcomes, reduce emergency room usage and contain costs.

Situation & Opportunity

Limited member support and knowledge, insufficient clinic access, and a provider shortage resulted in low member engagement and the misuse of hospital emergency rooms (ER) for non-urgent care. Inappropriate ER usage diverted resources from critical cases, overcrowded facilities, disrupted care continuity between patients and doctors, and raised overall costs.

By enhancing support services and educating members on their options, the HMO could break down care barriers and ensure their members received the right level of care at the right time, saving everyone time and money while boosting member health and satisfaction.

Success Strategy

To remedy the HMO’s challenges, Carenet crafted a customized, multi-pronged solution featuring both inbound and outbound services, including:

24-7 Nurse Advice – Easily accessible, around-the-clock medical care was provided by Carenet’s highly skilled registered nurses. After conducting a thorough symptom analysis, they directed members to the most appropriate level of care whether it was an at-home treatment or a visit to their physician, an urgent care facility or the ER.

Proactive Outreach – By employing Carenet’s cost-effective agentless-messaging technology, the HMO was able to quickly communicate to a broad audience their services, such as the Nurse Advice line and urgent-care facilities with extended hours. In addition, Carenet’s engagement team personally contacted frequent ER users to educate them on alternative, less-expensive options and to reinforce the importance of the primary medical home.

Expanded Member Support – Operating as a seamless extension of the HMO, Carenet’s Member Support team augmented the plan’s customer care service by providing support during high-volume periods, after hours, and on weekends and holidays.  Aid ranged from benefit eligibility questions and translation services to provider referrals and transportation coordination.

Performance Delivered

By collaborating with Carenet, the HMO was able to diminish inappropriate ER usage, optimize their operations, and improve member engagement, health and satisfaction while containing costs. Eighty-eight percent of the contacted members were unaware of their options and a post-campaign survey indicated that the majority of agentless-messaging recipients would first turn to the Nurse Advice service instead of the ER for future care.

In just one year, Carenet diverted 65 percent of the callers from the ER to a more appropriate level of care resulting in an annualized savings of $3.25 million.

Become a Success Story

Working with the government requires a deep understanding of its unique populations, regulatory measures, and the challenges with providing high-quality care while facing growing financial demands. Nearly 25 years of experience with both Medicare and Medicaid programs has given Carenet the know-how needed to implement solutions that streamline processes, cut spending and boost efficiencies.

Carenet’s services improve member engagement, compliance and vitality by encouraging healthy behavior such as well-child exams, perinatal care, screenings and immunizations. With the number of Medicaid members skyrocketing, it’s more vital than ever to have a partner like Carenet to help you do more with less while providing the utmost level of care.