“Self-care is already a challenge for dementia patients, and it is often made dramatically more complex by the presence of additional chronic conditions. By taking part in this program, we improve our ability to proactively manage patient health conditions in the home.”
Dr. Christopher Dennis
Chief Behavioral Health Officer, Landmark Health
The Ceresti Digital Care Management Program (DCMP) is optimized to proactively avoid unnecessary hospitalizations for high risk member who are reliant on family caregivers. Ideally, these member/caregiver dyads are already enrolled in Ceresti’s Family Caregiver Empowerment Program (FCEP) as a supplemental Medicare Advantage benefit.
Ceresti can identify high-risk dyads based on our proprietary analysis of member claims data and our prior assessments of caregiver’s strengths and weaknesses. High-risk dyads who are enrolled in the Ceresti’s DCMP are more actively and extensively monitored than those in the FCEP. Actionable alerts are also managed more diligently.
Preventing avoidable hospitalizations reduces members’ healthcare costs as well as caregivers’ burden. It also reduces the cognitive and functional declines that are associated with members’ experiences of hospitalizations and other acute events.
A Specialized Care Management Program For Members With Cognitive Impairment
Benefits for Plans
Benefits for Members with Cognitive Impairment
Members with Cognitive Impairment Incur More than 50% of Total Hospitalizations
Members with cognitive impairment (e.g., dementia, stroke, Parkinson’s, traumatic brain injury and other conditions that prevents effective self-management) represent about 30% of total Medicare Advantage Member. These Members incur more than 50% of total health plan hospitalizations and an even higher percentage of potentially preventable hospitalizations. A condition like dementia, on its own, drives 25-30% of a health plan’s total hospitalizations.
The Dementia Cost Multiplier Illustrated via Utilization and Costs
The Ceresti Remote Assessment Program engages these vulnerable and costly Members, through their family caregivers, to improve cost and quality outcomes for a population that is often “forgotten.”
Remote Monitoring of Members via Their Caregivers
We remotely monitor Members via assessments completed by their caregivers using the Ceresti app. Family caregivers, and in some cases paid caregivers, are uniquely able to provide insights into all chronic conditions that may impact a Member’s health. Engaged caregivers complete an average of 3 risk assessments per week.
Remote assessments trigger alerts that are mitigated by a Ceresti coach or forwarded to a care management team, based on mutually agreed processes and procedures.
We use claims and other data sources to risk-stratify Members based on their likelihood of an emergency department visit or a hospitalization. We predict the most likely underlying causes (e.g., dehydration, hypertension, medication side effect) for such an acute event (e.g., fall, stroke, infection) and use this information to drive Member-specific risk assessments that are specifically aimed at identifying the early warning signs of issues that could lead to a preventable hospitalization. In parallel, we train the family caregiver to look for specific signs and symptoms in the Member, which may include asking the caregiver to report specific biometrics (e.g., blood pressure, weight, etc.).
The ability to secure multiple risk assessments every week about Members, via their caregivers, is enabled by high levels of caregiver engagement (45 minutes per week) that we achieve using a combination of education, support and remote coaching.
Out modular technology-based approach supports a variety of deployment options. Ceresti can manage the Remote Assessment Program independently; or alternatively, we can support and train health plans and providers on how to integrate our technology and content into their existing care management capabilities.