Assuring data integrity is the top challenge to health risk stratification, according to a July 2016 healthcare benchmarks survey.
Two key trends emerging from a July 2016 survey on Stratifying High-Risk Patients highlight the need to occasionally eschew sophisticated tools in favor of basic, face-to-face care coordination.
As one survey respondent noted, “A key element [of stratifying high-risk patients] is building a trusting face-to-face relationship with each patient, knowing what they want to work on, coaching them and activating them.”
The first learning gleaned from the survey’s 112 respondents is that, despite the prevalence of high-end risk predictors, algorithms and monitoring tools, clinicians must occasionally step into the patient’s world—that is, literally enter their home—in order to capture the individual’s total health picture.
Fifty-six percent of respondents make home visits to risk-stratified patients; a half dozen identified the home visit as its most successful intervention for risk-stratified populations.
That inside look at the patient environment illuminates data points an electronic health records (EHRs) might never bring to light, including socioeconomic factors like limited mobility that could prevent a patient from keeping a follow-up appointment.
“I never know until the moment I enter the home and actually see what the environment is like whether we correctly predicted the need for high intervention (and get a return on it),” commented one respondent.
The second trend in risk stratification is the emerging laser focus on ‘rising risk’ patients, an activity reported by 72 percent of respondents. This scrutiny of rising risk populations helps to prevention their migration to high-risk status, where complex and costly health episodes prevail.
Other data points identified by the 2016 Stratifying High-Risk Patients survey include the following:
- Almost four-fifths of 2016 respondents have programs to stratify high-risk patients, and the infrastructures of more than half of these initiatives utilize clinical analytics, predictive algorithms, EHRs and other IT tools to manage care for high-risk patients.
- The reigning health risk calculator continues to be the LACE tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits), used by 45 percent in 2016, versus 33 percent two years ago.
- For more than a quarter of 2016 respondents, assuring data integrity remains a key challenge to risk prediction.
- A case manager typically has primary responsibility for risk stratification, say 52 percent of respondents.
- Diabetes is the most prevalent clinical condition among high-risk patients, say 47 percent.
- At least 70 percent report reductions in hospitalizations and ER visits related to risk stratification efforts.
- Improvement in the highly desirable metric of patient engagement is reported by 74 percent of respondents.
Tags: data integrity, health risk calculator, LACE tool, rising risk patients
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