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Essentia Health Virtual Telemedicine Services Support Rural Hospitals and Clinics

March 13th, 2018 by Patricia Donovan

Essentia Health conducts 5,000 virtual visits annually.

There may be some challenges associated with Essentia Health’s comprehensive telemedicine program, but provider engagement isn’t one of them.

“In the seven years I have been with Essentia Health, I have not gone to any provider to ask them to do telehealth,” notes Maureen Ideker, RN, BSN, MBA, the organization’s senior advisor for telehealth. Instead, physicians seek out Ms. Ideker, asking to be connected to any of Essentia Health’s six hospital-based and more than 20 clinic-based telehealth services.

Such robust telemedicine adoption among Essentia Health’s more than 800 physicians may be one reason why the organization averages 5,000 virtual visits annually, and why it has another 10 to 20 new telehealth offerings in development, according to Ms. Ideker’s presentation during Telemedicine Across the Care Continuum: Boosting Health Clinic Revenue and Closing Care Gaps.

The largely rural footprint of Essentia Health, which touches the three states of Minnesota, Wisconsin and North Dakota, is ideally suited to telehealth implementation. During this March 2018 webinar, which is now available for rebroadcast, Ms. Ideker outlined her organization’s telehealth program models, history of program development, and equipment and staffing requirements. She also shared key program outcomes, such as the impact of remote patient monitoring on hospital readmissions and clinic ROI from telehealth.

For example, the 30-day readmission rate for Essentia Health patients with heart failure remotely monitored at home is 2 percent, versus its non-monitored heart failure patients (9 percent) and the national 30-day readmissions average of 24 percent.

Essentia Health’s hospital-based telemedicine began with an emergency room platform, which includes pediatric ER and pharmacy and toxicology and a soon-to-be-added behavioral health component. Today, hospitalist and stroke care are the largest of Essentia Health’s hospital-based telemedicine programs, explained Ms. Ideker. These virtual services support Essentia Health’s rural hospitals in five key ways, including the avoidance of unnecessary patient transfers.

On the outpatient side, the 20-something tele-clinic based services developed by Essentia Health over the last seven years run the gamut from allergy and infant audiology to urology and vascular conditions, she explained. Her organization’s telemedicine approach to opioid tapering is catching on across Minnesota, she added.

And while it is appreciative of its providers’ enthusiasm, Essentia Health approaches telehealth development with precision, consulting data analytics such as metrics on annual health screenings to create target groups for new services. The launching of a new telemedicine service can take up to twelve weeks, using a 75-item checklist and an implementation retreat and walk-through, Ms. Ideker explained.

In closing, Ms. Ideker shared several innovation stories from its portfolio of telehealth offerings, including Code Weather, employed during hazardous weather for patient safety reasons and to reduce cancellations of appointments, and a gastroenterology initiative designed to reduce no-show rates.

Listen to Maureen Ideker explain how Essentia Health pairs remote patients with hospital- and clinic-based telehealth services.

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Posted in Avoidable ER Use, Behavioral Health, Care Management, Chronic Care Management, Data Analytics, Diabetes Management, Hospital Readmissions, Hospitals, Medication Management, Prescription Drugs, Reducing Readmissions, Remote Monitoring, Telehealth & Telemedicine | Comments Off on Essentia Health Virtual Telemedicine Services Support Rural Hospitals and Clinics

From Last Place, Bronx Communities Now Prize Culture of Health

December 7th, 2017 by Patricia Donovan

Barely eight years ago, the Bronx landed at the very bottom of the first county health rankings issued by the Robert Wood Johnson Foundation (RWJF) —the least healthy of 62 New York counties, to be exact.

It didn’t help that as a borough, the Bronx topped a few other lists compiled by New York officials, including the highest prevalence of obesity and diabetes and the top consumers of sugary drinks.

Rather than discourage this diverse borough, however, these rankings galvanized residents and a number of Bronx organizations, including the Bronx Institute of Health, to partner and examine facets of community life to see where health might be improved. Under the hash tag and rallying cry of #Not62, the coalition’s reach has extended into Bronx schools, housing and even local food stores known as bodegas as it attempts to reimagine and enhance community health.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webcast now available for rebroadcast, Charmaine Ruddock, project director, Bronx Health REACH, charted the path to some of the innovative community health partnerships forged by her organization.

Formed in 1999 with a grant from the Centers for Disease Control and Prevention (CDC), Bronx Health REACH (shorthand for “racial and ethnic approaches to community health”) is charged with eliminating racial and ethnic disparities in health outcomes, particularly those related to diabetes and heart disease, in Bronx populations. Since its inception, Bronx Health REACH has grown from five to more than 70 community-based organizations, schools, healthcare providers, faith-based institutions, housing, social service agencies and others.

“Those founding partners were particularly concerned that Bronx Health REACH not be seen as a program per se, but as a catalyst for creating a movement around health and well-being in the community,” explained Ms. Ruddock.

From early focus groups, Bronx Health REACH determined that community members not only felt disrespected by the healthcare system, but also powerless to advocate on their own behalf for better services. Those findings helped to shape the Bronx Health REACH mission and subsequent efforts.

Outreach began at the organizational level, such as examining the way a local church provided meals at church events. The coalition brainstormed ways to prepare those meals in a healthier manner, supplementing the church’s work with nutrition training that quickly spread throughout the faith community. From there, the program applied that approach to the food offered during school meals and via vending machines, and eventually within the local food retail environment, which consists principally of bodegas.

Today, the scope of Bronx Health REACH is broad, encompassing street safety, physical activity and overall wellness, among other areas. Its early work with bodegas has grown from demonstrations and tastings of healthy foods to the formation of a Bronx bodega work group and a new Healthy Bodegas marketing initiative. It has engaged farmers’ markets in its objective of increasing healthier food options. To that end, healthcare providers now issue “prescriptions” for fruits and vegetables that are accompanied by ten-dollar coupons.

The transformation is visible in the community, Ms. Ruddock notes. Today, some previously padlocked playgrounds are open; murals by visiting artists that adorn the walls of local housing are left alone for all to enjoy.

However, a great deal of work remains. “We have given ourselves as a goal that by 2020, we will establish a multi-sector infrastructure working with housing groups, economic development groups, and others as the first step in addressing many of the health-related factors and issues,” explained Ms. Ruddock.

But for now, the enthusiasm and contributions of Bronx residents have not gone unrewarded. In 2015, just five years after receiving its disappointing health ranking, the Bronx was one of eight recipients of the RWJF’s Culture of Health prize. The prize is awarded to communities that work to ensure residents have the opportunity to live longer, healthier and more productive lives.

Listen to Charmaine Ruddock explain how early findings from focus groups helped to shape Bronx Health REACH initiatives.

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Posted in Chronic Care Management, Diabetes Management, Disease Management, Dual Eligibles, Medicaid, Medicare, Obesity, Patient Engagement, Population Health Management, Social Determinants of health, Wellness/Prevention | Comments Off on From Last Place, Bronx Communities Now Prize Culture of Health

Community Health Partnerships Can Change the Culture of Poverty: 2017 Benchmarks

November 28th, 2017 by Patricia Donovan

Community health partnerships address unmet needs, providing services related to transportation, housing, nutrition and behavioral health.

For residents of some locales, community health partnerships (CHP) —alliances between healthcare providers and local organizations to address unmet needs—can mean the difference between surviving and thriving, according to new CHP metrics from the Healthcare Intelligence Network (HIN).

“We could not survive without community partnerships. Our patients thrive because of them. They are critical to help change the culture of poverty that remains in our community,” noted a respondent to HIN’s 2017 survey on Community Health Partnerships.

Partnerships can also mean the difference between housing and homelessness. According to the survey, more than a quarter of community health partnerships (26 percent) address environmental and social determinants of health (SDOH) like housing and transportation that can have a deleterious effect on population health.

“To date, we have housed 49 families/individuals who were formally homeless or near homelessness,” added another respondent.

“Social health determinants are more important than ever to managing care,” said another. “Community health partnerships make a big impact when it comes to rounding out care.”

Motivated to improve population health, healthcare providers are joining forces with community groups such food banks, schools and faith-based organizations to bridge care gaps and deliver needed services. The majority of community health partnerships are designed to improve access to healthcare, say 70 percent of survey respondents.

Eighty-one organizations shared details on community health partnerships, which range from collaborating with a local food bank to educate food pantries on diabetes to the planting of community gardens to launching an asthma population health management program for students.

Seventy-one percent conduct a community health needs assessment (CHNA) to identify potential areas for local health partnerships. Priority candidates for 36 percent of these partnerships are high-risk populations, defined as those having two or more chronic medical conditions.

Overall, the survey found that 95 percent of respondents have initiated community health partnerships, with half of those remaining preparing to launch partnerships in the coming year.

Other community health partnership metrics identified by the 2017 survey include the following:

  • Local organizations such as food banks top the list of community health partners, say 79 percent.
  • The population health manager typically has primary responsibility for community health partnerships forged by 30 percent of respondents.
  • Foundations are the chief funding source for services offered through community health partnerships, say 23 percent. However, funding remains the chief barrier to community health partnerships, say 41 percent.
  • Forty-five percent have forged community health partnerships to enhance behavioral health services.
  • Two-thirds attributed increases in clinical outcomes and quality of care to community health partnerships.
  • Forty-four percent reported a drop in hospital ER visits after launching community health partnerships.

Download an executive summary of results from the 2017 Community Health Partnerships survey.

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Posted in Behavioral Health, Care Coordination, Care Transitions, Chronic Care Management, Diabetes Management, Health Risk Assessment, Healthcare Costs, Healthcare Trends, Medicare, Patient Satisfaction, Population Health Management, Primary Care Practice, Social Determinants of health, Transitions in Care, Value-Based Reimbursement | Comments Off on Community Health Partnerships Can Change the Culture of Poverty: 2017 Benchmarks

Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

October 5th, 2017 by Patricia Donovan

More than 70 percent of healthcare organizations have created formal patient engagement initiatives, according to 2017 benchmarks from the Healthcare Intelligence Network.


To identify individuals that are poorly engaged in their health, nearly two-thirds (63 percent) of healthcare organizations mine clinical data analytics, according to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network, while 37 percent screen patients for social determinants of health related to housing, care access, transportation, nutrition and finances.

Patients who screen positive for social determinants of health (SDOH) and individuals with diabetes are typically the most difficult populations to engage, according to 2017 survey benchmarks.

Thirty-five percent of respondents to the September 2017 survey said the presence of SDOHs, which the World Health Organization defines as “conditions in which people are born, grow, live, work and age,” pose the greatest challenge to health engagement, while 26 percent said a diabetes diagnosis presents the top clinical challenge to engagement interventions.

One-quarter report some resolution of SDOH factors resulting from engagement efforts.

To improve engagement, 75 percent of respondents rely on education of patients, family and caregivers, supported with telephonic outreach (13 percent) and home visits (13 percent).

Efforts by 71 percent of respondents to create a formal patient engagement program underscore the critical role of engagement in healthcare’s value-based care and reimbursement models, particularly in regards to chronic illness.

In other survey findings:

  • Patient experience rankings are the most reliable measure of engagement program success, say 43 percent.
  • For one quarter of respondents, patient engagement is the primary domain of case managers.
  • Eighty-three percent saw quality metrics improve as a result of patient engagement efforts.
  • Half attributed a drop in hospital emergency room visits to their patient engagement interventions.

Download an executive summary of the 2017 Patient Engagement Survey.

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Posted in Care Coordination, Case Management, Chronic Care Management, Data Analytics, Diabetes Management, Patient Engagement, Quality Improvement, Social Determinants of health, Value-Based Reimbursement | Comments Off on Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

Top 2017 Chronic Care Management Modes and 13 More CCM Trends

May 2nd, 2017 by Patricia Donovan

Availability of chronic care management rose 14 percent from 2015 to 2017, according to new metrics from the Healthcare Intelligence Network.

The majority of chronic care management (CCM) outreach is conducted telephonically, say 88 percent of respondents to a 2017 Chronic Care Management survey by the Healthcare Intelligence Network (HIN), followed by face-to-face visits (65 percent) and home visits (44 percent).

This preference for telephonic CCM has remained unchanged since 2015, when HIN first canvassed healthcare executives on chronic care management practices. More than one hundred healthcare companies completed the 2017 CCM survey.

In addition, the April 2017 CCM survey captured a 14 percent increase in chronic care management programs over the two-year-span: from 55 percent in 2015 to 69 percent in 2017. Three-fourths of 2017 responding CCM programs target either Medicare beneficiaries or individuals with chronic comorbid conditions, with management of care transitions the top CCM component for 86 percent of programs.

In terms of reimbursement, payment levels for CCM services remained steady at 35 percent from 2015 to 2017. However, HIN’s second comprehensive CCM survey determined that 32 percent of respondents currently bill Medicare using CMS Chronic Care Management codes introduced in 2015.

Forty percent of these Medicare CCM participants believe CMS’s 2017 program changes will reduce administrative burden associated with CCM, the survey documented.

Other metrics from HIN’s 2017 CCM survey include the following:

  • A diagnosis of diabetes remains the leading criterion for CCM admission, said 92 percent;
  • Use of healthcare claims as the top tool for identifying or risk-stratifying individuals for CCM continues at 2015’s 70-percent levels;
  • Seventy percent of respondents target individuals with behavioral health diagnoses for CCM interventions;
  • Patient engagement remains the top challenge of chronic care management, with just under one-third of 2017 respondents reporting this obstacle
  • Responsibilities of RN care managers for CCM rose over two years, with 43 percent of 2017 respondents assigning primary CCM responsibility to these professionals (up from 29 percent in 2015); and
  • Two-thirds of respondents observed a drop in hospitalizations that they attribute to chronic care management.

Download an executive summary of 2017 Chronic Care Management survey results.

Posted in Care Coordination, Care Management, Care Transitions, Chronic Care Management, Diabetes Management, Healthcare Benchmarks, Medicare, Telephonic Case Management | Comments Off on Top 2017 Chronic Care Management Modes and 13 More CCM Trends

MACRAeconomics: Chronic Care Management Is the Future of Medicare Reimbursement

November 3rd, 2016 by Patricia Donovan

The newly finalized 2017 Physician Fee Schedule expands Chronic Care Management codes to complex patients with multiple chronic illnesses.

Managing a Medicare population, particularly when the majority has two or more chronic illnesses, can be daunting. But in the current realm of healthcare reimbursement, the care of these beneficiaries is rife with opportunity.

“Depending on the manner in which you’re managing your Medicare Part B demographic, you have an opportunity to generate from 100 to 120 percent of the Medicare fee schedule under MACRA,” noted Barry Allison, chief information officer, the Center for Primary Care, during Physician Chronic Care Management Reimbursement: Setting MACRA’s MIPS Path for 2017.

During this October 2016 webinar now available for replay, Allison described how early adoption of Medicare’s Chronic Care Management (CCM) Reimbursement program enhanced the Center’s MACRA-readiness under the Merit-based Incentive Payment System (MIPS) path. By identifying the more than three-quarters of its 24,000 active Medicare beneficiaries that met CMS’s CCM requirements, the Center had a ready pool of patients on which to overlay CMS’s care coordination best practices and begin earning crucial CCM revenue.

“CMS recognizes that care management is a critical component of primary care. It contributes to better health and care for individuals, as well as reduced spending,” said Allison, who estimates his 40-provider organization is the largest chronic care management initiative in the Southeast.

Using the value-based modifier data available within CMS’s Quality Use and Resource Report (QRUR), The Center for Primary Care further identified its percentage of high-risk Medicare patients for more focused care management.

Accessing and reviewing QRUR reports, available from the CMS Enterprise Identity Management (EIDM) desk, is an essential prerequisite to MACRA participation, advised Allison, who also detailed the type of reports and data available from the QRUR. “Procure that data as soon as possible, because you can learn a lot about what CMS will be looking for in the future, and how the value-based modifier will actually become a part of that MACRA multi-pronged approach.”

While his organization’s CCM program utilized ENLI software to identify ‘hot-spotter’ data elements such as unfilled prescriptions or ER visits for specific conditions, physician practices that lack this technology still have many tools at their disposal—even appointment scheduling software—to identify high-risk patients.

“Open up consistent lines of dialogue and engage your providers. Sit down with them and say, ‘You know your patients better than anyone else. Tell us who to reach out to.'” With or without CCM software, practices should “document, document, document” the amount of time devoted to CCM, as well as how that time benefited patients.

Long-term planning rather than a reactive view will better position physician practices for success under MACRA’s Quality Payment Program, Allison concluded. The Center is already estimating how it will fare under Medicare’s newly finalized 2017 Physician Fee Schedule (PFS). Next year’s PFS significantly updates CCM, offering new codes for complex chronic care management and for extra care management furnished by a physician or practitioner following the initiating visit for patients with multiple chronic conditions.

“For us, CCM is not really focused on the near term revenue as much as it is about the long term action-reaction we can have in the patient’s life, and how our physicians are paid over the next three years.”

Click here for an interview with Barry Allison on the MACRA Prerequisite of Procuring QRUR Performance Data to Maximize MIPS Success.

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Posted in Care Coordination, Care Management, Chronic Care Management, Data Analytics, Diabetes Management, Electronic Health Records, MACRA, Medicare, Wellness/Prevention | Comments Off on MACRAeconomics: Chronic Care Management Is the Future of Medicare Reimbursement

Engage a Pharmacist and 12 More Prescriptions for Medication Management

October 20th, 2016 by Patricia Donovan

Half of medication management programs engage retail or community pharmacists in 2016.

When should a pharmacist be brought in for a medication management consultation?

When the patient requests a consult, experiences general medication adherence issues, or suffers complications from medications, say respondents to the 2016 Medication Management survey by the Healthcare Intelligence Network.

The 101 respondents to the August 2016 survey also indicated that as a general medication management guideline, and with or without a pharmacist’s involvement, polypharmacy patients, individuals taking high-risk medications, those registering frequent ER or inpatient stays and those transitioning between care sites should receive priority.

Drilling down to clinical red flags for medication management, a diagnosis of diabetes is a key indicator, say 84 percent, followed by congestive heart failure or hypertension, say 81 percent of respondents.

Despite the inclusion of pharmacists in 90 percent of medication management programs, 42 percent of respondents say pharmacists are not currently reimbursed for medication management-related tasks.

Other medication management metrics documented by the survey include the following:

  • The three most common components of medication management programs are education and health coaching (71 percent), a medication needs assessment (69 percent) and pharmacist counseling (68 percent).
  • A pharmacist-driven clinical assessment is the most reliable standard for measuring medication management, say 63 percent of respondents.
  • E-prescribing and aids such as medication event monitoring system (MEMS) caps, pillboxes and calendars are the most common medication management tools, according to 49 percent of participants.
  • Patient-reported medication data is the information most commonly assessed for medication management, say 78 percent, closely followed by medication refill patterns (75 percent) and claims data (53 percent).
  • Half of responding medication management programs engage a retail or community pharmacist.
  • Fifty-eight percent of respondents not currently engaged in medication management plan to launch a program in the coming year.
  • Forty-four percent of respondents share electronic health records for medication management purposes.
  • Beyond a pharmacist-driven assessment, the Medication Possession Ratio (MPR) is the key measure of medication management for 31 percent of respondents.

Click here to download an executive summary of survey results: Medication Management in 2016: Polypharmacy, Diabetes Patients Priorities for Pharmacist-Led Interventions.

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Posted in Accountable Care Organizations, Avoidable ER Use, Chronic Care Management, Diabetes Management, Medication Management, Prescription Drugs, Transitions in Care | Comments Off on Engage a Pharmacist and 12 More Prescriptions for Medication Management

Infographic: The Data Behind Diabetes

July 22nd, 2016 by Melanie Matthews

The number of people living with diabetes has quadrupled since 1980, growing to more than 400 million. And with this rise in disease, sales of diabetes-related products have also climbed. In fact, in 2015, American consumers spent $592 million on such products, according to the World Health Organization.

Managing diabetes requires a proper balance of professional medical management, blood sugar control, and maintaining a healthy diet. So there is great value in understanding the diabetic patient and consumer journey through each step of the management process, all the way from the doctor’s office to the grocery aisles. And today, thanks to the power of data insights, healthcare providers and physicians, product manufacturers, and retailers can better tailor their offerings and experiences to aid diabetic patients and consumers in their path to healthy living.

A new infographic by Nielsen reflects key insights around the diabetic consumer.

Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care ManagementReal-time remote management of high-risk populations curbed hospitalizations, hospital readmissions and ER visits for more than 80 percent of respondents and boosted self-management levels for nearly all remotely monitored patients, according to 2014 market data from the Healthcare Intelligence Network (HIN).

Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management profiles a successful eight-year initiative by New York City Health and Hospitals Corporation’s (NYCHHC) House Calls Telehealth Program that significantly lowered patients’ A1C blood glucose levels.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

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Can Digital Health Drive Down Diabetes Costs?

April 14th, 2016 by Patricia Donovan

The majority of organizations engage in digital health to enhance patient satisfaction with their healthcare experience, according to March 2016 HIN market metrics.

New metrics from the Healthcare Intelligence Network (HIN) have determined that 58 percent of digital health initiatives target patients with diabetes, the global cost of which is now $825 billion per year, according to a new report from the Harvard T.H. Chan School of Public Health.

Harvard, the World Health Organization and nearly 500 researchers around the globe recently conducted the largest-ever worldwide study of diabetes levels.

Respondents to the February 2016 Digital Health Survey by the Healthcare Intelligence Network report that, along with the diabetes population, individuals with congestive heart failure and hypertension are also closely monitored by digital health programs.

Weight and vital signs, key indicators that can signal complications with diabetes and other chronic conditions, are the health activities most frequently monitored by digital health, said 63 percent of survey respondents, a trend Melanie Matthews, HIN executive vice president and chief operating officer, would like to see expanded.

“In our device-driven era, many individuals already use at least one electronic tool for health-related reasons. Coaching people to use digital health to monitor vital signs like weight and blood pressure will foster self-management.” And with chronic conditions held in check, the industry should see a drop in hospital utilization and associated cost, Ms. Matthews predicted.

Digital health, also called ‘connected health,’ leverages technology to identify, track and manage patients’ health problems.

The survey also identified these digital health trends:

  • Individuals at moderate risk for hospitalization are the most engaged in digital health, said one-quarter of respondents.
  • Seventy percent said the principal goal of digital health is to elevate patient satisfaction with the healthcare experience.
  • Individuals at risk of a health crisis or hospital admission are the most heavily invested in digital health, according to one-quarter of respondents.
  • Mobile and tablet apps are the front-running digital health platforms, say 78 percent of these respondents, with online health education the principal digital health activity for 58 percent.
  • Overall, patient engagement proves the biggest digital health hurdle to overcome, say 23 percent of respondents.

For more 2016 digital health metrics, download the Digital Health Survey executive summary.

Posted in Avoidable ER Use, Chronic Care Management, Diabetes Management, Healthcare Wearables, Patient Engagement, Remote Monitoring, Value-Based Reimbursement | Comments Off on Can Digital Health Drive Down Diabetes Costs?

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

November 3rd, 2015 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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Posted in Care Coordination, Chronic Care Management, Diabetes Management, Disease Management, Health Risk Assessment, Population Health Management | Comments Off on Health Risk Stratification Model: How Well Do You Manage ‘Falling Risk’ Populations?

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