Responding to regulatory changes that significantly expanded Blue Shield of California’s membership population with the most complex care needs, the organization’s leaders recognized that they needed to transform their technology infrastructure to better support care managers. For the Care Connect solution, Blue Shield of California wins Healthcare Innovation’s second-place Innovator Award for 2024.
The legacy solutions that Blue Shield care managers previously relied on had some clear limitations. Prior to the launch of Care Connect, nurses and other team members, including social workers and behavioral health therapists, had to access as many as 13 different systems and spend 20 to 30 minutes trying to gather the information to be prepared to talk with a member about their care, says Tracy Alvarez, vice president of medical care solutions at Blue Shield. “Also, reporting was a very manual process,” she adds. “The other issue is that a point solution really stymies our ability to think creatively and with that innovative mindset about what we want to do and how to take the process to that next level to help manage the care of our members.”
In 2021, the nonprofit payer did an industry assessment of best-in-class solutions in this space. “We spent several months defining current requirements and responding to legislative changes, but also thinking strategically about where we want to go to serve more members holistically and meet our mission statement,” recalls Bill Giard, vice president of enterprise architecture and health innovation. After looking at the top vendors in this space, Blue Shield leaders ultimately made a decision to build out and co-design a solution with Salesforce.
Blue Shield has worked with Salesforce for more than 15 years in various capacities, but this was its first time using the vendor’s Health Cloud. “We knew that building this solution with Salesforce gave us more flexibility, but more importantly, it gave us the means technically to be able to rapidly respond to new member needs and get real-time access to information,” Giard adds.
The Care Connect platform gives care managers a much better view of their members. “One of the tools that our care managers use is a health risk assessment,” Alvarez explains. “Our care managers now have the ability to see the member’s health risk assessment, and then bring in all of this information about the member in a 360-degree view.” That includes things like labs, prescription data, authorizations, and past claims so the care manager can see if the member has been in an emergency room or had a hospital stay recently.
“They also have access to what we call ‘next best actions.’ If a member answers a question a certain way, it will prompt the care manager through additional actions,” Alvarez says. For example, if a member says they are feeling down or having anxiety, the system prompts the care manager to perform a behavioral health assessment. If a member mentions they have food insecurity or an issue with housing or transportation, then resources pop up for the care manager to relay and share with the member. "Having automated prompts provides us extra time and ability to work with our members, which is truly game-changing,” she adds.
Because of the tight timeline, the project required a strong sense of cooperation between the IT and business teams involved. “We did use an Agile process,” Giard explains. “We had the clinical team participating in every two-week sprint, testing out the functionality and providing real-time feedback. I think that early validation was critical. We also have a set of extended care providers who do in-home visits with members, and we worked with them to improve their ability to get real-time information and help them better understand the members that they're visiting.”
“We basically had nine months to get this done, and it would not have been successful without the commitment of both the business and IT and quite frankly, our entire organization. They made this a priority,” Alvarez adds. “But I think this is a really good example of two very different functional teams coming together, sharing their expertise and trusting each other to do their part – which was key.”
Blue Shield has been measuring some of the ways the new system already is impacting quality of care and patient and provider experience:
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Blue Shield has increased outreach, case creation, and care plan completion by 700 percent for its Dual Special Needs Population.
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It has achieved 100 percent compliance in creating and communicating care plans to care managed members.
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Blue Shield leveraged Care Connect to align with new California Department of Health Care Services (DHCS) initiatives on population health management by empowering multidisciplinary care teams with real-time data to address members’ unique needs and enable more seamless collaboration.
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Blue Shield achieved significant operational efficiencies by automating interdisciplinary care team summaries, reducing processing time from 30 minutes to just seconds, which gives care managers more time to connect with members.
Care Connect is the foundational use case for reimagining and improving the member journey at Blue Shield, Giard and Alvarez say. The organization is looking to replace costly point solutions with an advanced cloud-based platform. Other potential uses include member engagement, customer service, user management, appeals and grievance, pharmacy, and more.
In 2024, Blue Shield will be rolling this operating model out to more than 400,000 Medi-Cal members, with plans to expand its population health management operating model to scale with overall membership growth.
“We are looking at how we extend it even farther to more members, so it's an ever-growing spectrum of being able to apply our passion for improving the health of our members to as many areas as we can, linking that to other programs for preventive care or for when we are measuring our discharge and transition-of-care efforts,” Giard says.
In addition to the internal improvements, through the Salesforce partnership, Blue Shield provided recommendations for key platform enhancements, which are now commercially available in Salesforce Health Cloud and can be leveraged by other payers and healthcare partners. Blue Shield’s Care Connect subject matter experts are sharing their expertise, learnings, and tailored customizations with healthcare and technology peers through case studies and speaking engagements.
“We're quite proud,” Giard says, “and happy to support other payers on similar journeys to help their members.”