The process of identifying high-risk, high-cost patients can be formal or informal. You can use internal sources; when TPR goes in, that is one of the baselines of understanding. We understand who the patients are and what the population is, because if they have not been using data or have not been in an Advanced Primary Care initiative, it is highly unlikely the practice will have a quantitative method in place when we arrive.
We begin by asking the practice providers who the sickest patients are. Second, we can use data available at the practice level, such as registries or reports that can be run from the EHR.
Third, we also look at the kind of data they get from external sources. For example, do they receive reports from payors that show some utilization activity? Many of those reports may be somewhat aged. They are not necessarily timely, which raises actionability questions. However, we found there are reports coming out from payors, particularly about recent ER use or hospital discharges, that are more timely, which allow the practices to look at data—still retrospectively in most cases but much more quickly than they were able to in the past.
And finally, hospital admission and discharge information is important. Depending on the model in a PCP, if a physician is not the admitting physician— that is, if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information.
People may think physicians know about their patients being in the hospital, but that is not always the case.
(Note: Taconic Professional Resources offers professional training and practice optimization to organizations aspiring to become a patient-centered medical home and/or join a medical neighborhood.)