care management
care_mgmt_indDefinition
ISO-11179 Definition
A coordinated set of activities and interventions designed to improve health outcomes and reduce unnecessary healthcare utilization for health plan members with complex chronic conditions, high predicted costs, or identified care gaps through proactive outreach, care coordination, and clinical support. Care management programs include disease management for specific chronic conditions, case management for high-complexity members with multiple comorbidities, transitional care management following hospital discharge to prevent readmission, and preventive care outreach to close HEDIS quality measure care gaps. CMS requires Medicare Advantage plans to provide care management services to high-risk members as a condition of participation, and care management effectiveness is measured through HEDIS quality measures, readmission rates, and total cost of care trends.
Healthcare data teams build care management analytics that identify eligible members for each program type using risk stratification and care gap data, track program enrollment and intervention completion rates, measure clinical and financial outcomes for care management participants, and calculate return on investment by comparing care management costs against avoided healthcare expenditure.
Standard Abbreviation
care_mgmt_ind
Category
Production DDL — FACT_QUALITY_MEASURE
CREATE OR REPLACE TABLE FACT_QUALITY_MEASURE (
qlty_key INTEGER NOT NULL -- surrogate key,
mbr_key INTEGER NOT NULL -- FK to DIM_MEMBER,
plan_key INTEGER NOT NULL -- FK to DIM_PLAN,
meas_yr SMALLINT -- measurement year,
hedis_meas_cd VARCHAR(20) -- HEDIS measure code,
denom_ind CHAR(1) -- denominator eligible,
numer_ind CHAR(1) -- numerator met,
excl_ind CHAR(1) -- exclusion indicator,
gap_open_ind CHAR(1) -- care gap open,
star_rtg_nbr DECIMAL(3,1) -- star rating,
qlty_scr DECIMAL(5,2) -- quality score,
perf_thrsh_pct DECIMAL(5,2) -- performance threshold,
raf_scr DECIMAL(10,3) -- risk adjustment factor,
outreach_cnt SMALLINT -- outreach attempts,
load_dt TIMESTAMP_NTZ NOT NULL -- load timestamp
);
Standard Snowflake DDL for the canonical quality table. Convert to BigQuery or Databricks →
Why This Term Matters
Quality measure data determines how payers and providers are rated and reimbursed under CMS Stars, HEDIS, and value-based care contracts. Data engineers who understand quality terminology build measure calculation pipelines that correctly attribute patients, apply denominator exclusions, and flag documentation gaps before submission deadlines. Incorrect quality data directly affects star ratings, pay-for-performance bonuses, and Medicare Advantage plan bids.
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