Achieving higher-quality health outcomes by closing gaps in care

The Product

Wellframe is a platform for health plans to deliver digital, whole-person health management to their members, meeting those people on their own terms and in a convenient, easy-to-use format.

On the Wellframe mobile app, members connect directly via HIPAA-compliant chat with care management teams, customer service representatives, and other support staff who are integral to their health journeys. The app also serves as a way to deliver condition-specific educational content, reminders for appointments and medications, and more.

On the Wellframe web dashboard, health plan staff — primarily care managers, who support members who struggle with their chronic diseases or complex conditions — manage and prioritize their caseload, message and engage with their members, and customize their members’ experience with content appropriate to where their members are at.

Ensuring health plan members adhere to care guidelines is a tedious and highly inefficient process.

For a given age, gender, or condition, standards of care describe specific health-related recommendations that patients must follow to stabilize or improve health outcomes. As an example, according to these standards, a 65-year-old woman with diabetes is supposed to have:

• Annual Dental Visit

• Breast Cancer Screening

• Diabetes Eye Exam

• Diabetes HbA1c Test

• Colorectal Cancer Screening

• Adult Flu Vaccine

Each of these recommendations is derived from a codified rating system such as HEDIS (Healthcare Effectiveness Data and Information Set), CMS Star Ratings, and CAHPS (Consumer Assessment of Healthcare Providers and Systems). Health plans use these sets of quality measures to assess overall performance. High ratings indicate the health plan provides high quality care to its members.

Health plans are incentivized to ensure that their members participate in all of the quality measures that apply to them—not only because they tend to be preventive care actions that keep members healthy and whole, but also because receiving high ratings on these quality measures provides direct financial value to the health plan. High ratings not only secure their reputation as an institution, but more importantly can bring in new business in the form of higher enrollment rates and increase revenue through federal reimbursements (specifically for Medicare and Medicaid members).

However, when a member has not completed all the actions that apply to them (for instance, in our example above, if the member has not had her annual Diabetes Eye Exam) — that is called a care gap.

Traditionally speaking, the method for identifying and closing care gaps is highly inefficient and manual: a list of care gaps is generated by cross-referencing quality measures against insurance claims data and identifying what is missing; the list is passed onto a care manager or quality assurance staff, who then call members out of the blue to suggest medical care; if the patient reports they have take the recommended action, staff spend additional cycles chasing down a paper trail to ensure the plan “gets credit” for closing the care gap. When it comes right down to it, closing a care gap this way is hard, and success rates are understandably low:

The challenge

How might Wellframe remove friction in the process to close a care gap?

Discover

I partnered with my Product Manager to conduct interviews with end-users, buyers, quality data managers, and quality standard administrators. These conversations helped us uncover insights about the care gaps/quality measures space. I led her through a customer journey mapping exercise to identify key pain points and product opportunities that we could then translate into features that addressed end-user tasks, behaviors, and motivations.

Plan 

We worked together to define an approach to building a care gaps solution into the core Wellframe platform. This included guiding my Product Manager through an exercise where we reviewed each user task we had previously defined and discussed how integral it would be to the project’s success — was it a must-have, a nice-to-have, or an enhancement?

From there, I created several prototypes to demonstrate each option, which we used to share our vision for the solution with a broad set of stakeholders. This format gave our organization flexibility based on differences in level of effort, time to market, and comprehensiveness of the feature set. As a team, we balanced user, business, and engineering goals, and prioritized and negotiated features for launch and beyond, to ensure that we released not just a Minimum Viable Product, but a Minimum Useful Product.

The solution that we arrived at has 3 essential functions:

1. On the backend of our product, Wellframe can receive a data file of identified care gaps from our health plan clients and link those gaps to the corresponding members on the Wellframe web dashboard;

2. Within the Wellframe web dashboard, a care manager can view gaps at the population or individual member level, and use existing features such as messaging or reminders to prompt those users to take action; and

3. Also within the web dashboard, the care manager may track the status of each care gap in question, to share progress taken towards closing them.

This feature has only just launched, so we are just beginning to collect data on its success among our end-users. However, I did learn many other things along the way, to improve my process: