Posts Tagged ‘health risk’

How Taconic IPA Embedded Case Managers Risk-Stratify High-Risk, High-Cost Patients

November 5th, 2013 by Jessica Fornarotto

Using a self-developed approach that combines elements of Geisinger’s Proven Health® Navigator, Johns Hopkins Guided Care Nursing and the Wagner Chronic Care Model, Taconic Professional Resources is assisting physician practices in the New York Hudson Valley to improve population health and care for their sickest patients through the use of embedded RN case managers.

During HIN’s webinar on Improving Population Health With Embedded Case Managers in an Open, Multi-Payor Community, Annette Watson, senior vice president of community transformation for Taconic, described how case managers identify high-risk, high-cost patients.

How does a case manager go in and identify who is high-risk or who is high-cost? You can do it a number of ways, and they can be formal and informal. You can use internal sources and when we do go in, that’s one of the baselines you have to understand. Who are the patients and what is the population? If they have not been using data or have not been in an Advanced Primary Care initiative, it’s highly unlikely that a practice has a quantitative method in place when we arrive.

We begin by asking the practice providers who are the sickest patients? We can then use data that’s available at the practice level, such as registries or reports, that can be run from the EHR. We also look at what kind of data they’re getting from external sources. Are they getting reports from payors that perhaps show some utilization activity?

One thing about many of those reports is that they may be somewhat aged. They’re not necessarily timely, which creates actionable questionability. But we’re finding more and more reports about recent ER use or discharges from payors that are more and more timely that allow the practices to look at data retrospectively in most cases, but much more quickly than they were getting in the past.

And when it comes to hospital admission and discharge information, many times in a primary care practice depending on the model, if they are not the admitting physician, whether it’s a specialist or a hospitalist or someone that comes through the ER, it’s not a given. People think they know about their patients being in the hospital. They don’t always, and that is a challenge and a workflow implementation that we often spend a lot of time on when we get into a practice — how to get the timely information about admissions and discharges.

We also implement new processes in the practice to formally assess the risk of patients using validated tools. In the Hudson Valley, the tool that was easily adopted and modified in a variety of EHR’s is from the American Academy of Family Physicians (AAFP). This tool allows for a quantifiable way to put a risk level on every patient in a practice who is seen, and it changes over time. It’s the kind of tool that when a case manager goes into a practice, we look at risk stratification as an important characteristic of identifying those patients and managing those patients over time.