One way HealthCare Partners Medical Group of California maintains the lowest hospital readmission rates in its history is by risk-stratifying their patients before placing them in a medical home that best suits their needs, explains Dr. Stuart Levine, corporate medical director.
The disease-specific approach is gaining followers as the industry navigates away from a fee-for-service environment toward a more evidence-based, protocol-driven approach that rewards not only clinical outcomes but also an organization’s ability to deliver value-based healthcare.
We use a predictive modeling tool, a dollar tool predictor, and a hierarchical condition categories (HCC) or HCC-like modeling tool to risk-stratify our patients before placing them in the medical home that best suits their needs. This could be hospice and palliative care, or a home care program where teams of physicians, nurse practitioners, case managers and social workers take care of chronically frail patients at home, meeting all of their needs.
HealthCare Partners also has a medical home program for patients with end-stage renal disease (ESRD). All patients are seen at the dialysis center, and that’s where their medical home is. They no longer come into offices. They are seen by nurse practitioners with backup nephrologists.
They’re not only getting their renal disease managed, but much more importantly, they’re getting all their primary care needs met.
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