Ochsner’s Standardized Risk Stratification, Care Coordination Protocols Boost Outcomes across Continuum

Monday, October 20th, 2014
This post was written by Patricia Donovan

Ochsner Health System’s scaling of a successful transitional care model across one region not only reduced duplication of calls to recently discharged patients but also quadrupled its connect rate—from about 20 percent to nearly 98 percent of discharged patients—and decreased rehospitalizations by about 15 percent.

All while remaining salary-neutral.

To achieve these results and others like them, Ochsner uniformly applied scripts, templates and protocols to processes across its care continuum, even assuming clinical oversight for some providers in external facilities to ensure standardization, explained Mark Green, assistant VP of transition management at Ochsner, during Moving the Metrics: Financial and Quality Returns from System-wide Care Coordination and Risk Stratification, an October 2014 webinar now available for replay.

To replicate these achievements, the nine-hospital system looks up and down its continuum for opportunities to collaborate in care coordination and has elevated its approach to risk stratification. This culture shift is a prerequisite for success in today’s value-based climate, Green estimates.

“A really critical step to understand is managing not only your ‘rising risk’ but also your ‘falling risk’ patient population,” he said, categorizing ‘falling risk’ as those whose conditions are under control and who can be handed off to a lower risk medical home or chronic disease management environment.

Healthcare doesn’t currently do a good job of moving ‘falling risk’ patients down the stratification model, he said, which leaves little room for newly diagnosed ‘rising risk’—an out of control CHF patient, for example.

Risk stratification is scalable, Green emphasized, from single providers without an electronic medical record to a large health system or accountable care organization. As a nine-hospital system, Ochsner’s risk segmentation approach relies heavily on automation and data analytics. For example, every Ochsner hospital patient is assigned a severity of illness (SOI) level that helps to guide individuals to the appropriate level of care. For example, all level 3 patients are automatically referred to complex case management.

During the webinar, Green shared several of Ochsner’s collaborations in risk stratification and care coordination, including an automated post-discharge telephonic follow-up for emergency department patients that replaced its siloed approach and has reduced avoidable ER use in the range of 13 to 15 percent depending on the payor and the location.

“We are very cognizant of and careful that we’re not driving too much business away from our emergency room if it’s appropriate. We’re just letting [staff] manage a higher risk population within their emergency room and giving them time to spend more of it with the patients.”

Listen to an interview with Mark Green.

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