Health Risk Stratification Model: How Well Do You Manage ‘Falling Risk’ Populations?

Tuesday, November 3rd, 2015
This post was written by Patricia Donovan

Health risk stratification is scalable, according to the experience of Ochsner Health System, whose scaling and centralization of risk stratification and care coordination protocols across its nine-hospital system drive ROI and improve clinical outcomes and efficiency.

Here, Mark Green, system AVP of transition management at Ochsner Health System, explains why health plans and providers need better control over ‘falling risk’ patients.

Regardless of your patient population, no matter how small or large, you’ve got a segment of your population that are healthy patients. You’ve got a certain percentage, about 40 percent, who are at very low risk.

About 20 percent of your population falls into a ‘rising risk’ segment. Those are patients with chronic diseases who are somewhat adherent and compliant. You’ve got some that are newly diagnosed with depression, and a comorbidity. Then you’ve got this very top 3 to 5 percent, which are your poorly controlled multiple comorbidities that need your absolute highest touch, whether it’s through complex case managers or other programs that are the highest touch of those patients.

That is the typical model in the United States where you see this segmentation. In this country, we do a relatively good job of understanding ‘rising risk’ patients. Those are your patients that are diabetic, and suddenly you see their A1C go out of control. You know they’re going off-track for some reason, whether it’s compliance, adherence, needing medication adjustments, or some other social interactions happening outside your care model. These are your ‘rising risk’ patients.

As the country begins to understand this risk stratification, it understands the ‘falling risk’ patients, too. For example, we had a congestive heart failure (CHF) clinic that was pretty successful in managing patients; they had approximately 100 patients in their CHF clinic. They were taking these complex CHF patients and sending them through education and hooking them up with complex case managers. Pretty soon they filled their entire clinic up and didn’t have any more access for new patients. It failed pretty quickly because they weren’t able to churn these patients.

As we began to do a root cause analysis of why this happened, to understand why we didn’t see the sustainability in this program, we realized it was because we never moved patients down that risk stratification model. We kept them in there forever. We received them, we managed them and we got them better. But we never moved them down, so we never had room for another newly diagnosed, out-of-control CHF patient.

That’s a really critical step to understand: managing not only your rising risk but also your falling risk patient population within the sub-categories of your overall risk segmentation. It’s a living organism moving in and out of these different components.

Source: Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination

http://hin.3dcartstores.com/Rethinking-Readmissions-Patient-Centered-Collaborations-in-Care-Transition-Management_p_4646.html

Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination explores Ochsner’s approach, in which standardized scripts, tools and workflows are applied along the care continuum, from post-hospital and ER discharge telephonic follow-up to capture of complex cases for outpatient management.

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