Posts Tagged ‘Risk Stratification’

Risk Stratification Targets the High-Risk, Curbs Utilization Across Continuum

February 19th, 2015 by Cheryl Miller

Preventive care and utilizing hospital and discharge information are critical for stratification, say a number of thought leaders from organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and often lead to improved clinical and financial outcomes. Here, some advice from these thought leaders.

Across the healthcare continuum, improved clinical and financial outcomes at organizations like Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), and Ochsner Health System were preceded by rigorous risk stratification of populations served.

“Humana encourages preventive care, and we are trying to prevent the most costly interventions by making sure we address things before they become big problems,” notes Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge. “It is successful so far. We have been able to reduce hospitalizations from what we expected by about 42 percent. We have been able to decrease our hospital readmission rate to 11 percent.”

Hospital admission and discharge information is critical for stratification, adds Annette Watson, RN-BC, CCM, MBA, senior vice president of community transformation for Taconic Professional Resources. “Depending on the model in a primary care practice (PCP), if a physician is not the admitting physician—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.”

“Our first step in launching Monarch’s Pioneer ACO program was to develop a population disease profile in risk stratification analysis,” contributes Colin LeClair, executive director of accountable care at Monarch HealthCare. “With the help of Optum Actuarial Solutions, we identified the eight most prevalent and costly conditions in our population. We then identified the largest cohort of high-risk patients best suited for Monarch’s care management programs. Ultimately we isolated the top 6 percent of high-risk patients with a diagnosis of diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or renal disease and found that of those patients, 6 percent account for 43 percent of total medical cost across the entire population. That analysis resulted in us targeting about 1,200 high-risk patients who have a similar constellation of issues.”

“You want to look at your high utilizers of care, because they’re using a great deal of care,” concludes Elizabeth Miller, RN, MSN, vice president of care management at White Memorial Medical Center, part of Adventist Health. “There’s potential for decreasing procedures, tests, ED visits, hospitalizations.”

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Hospital-Readmissions_p_4786.html

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement—data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

11 Statistics about Stratifying High-Risk Patients

November 20th, 2014 by Cheryl Miller

Healthcare organizations use a range of tools and practices to identify and stratify high-risk, high-cost patients and determine appropriate interventions. Most critical to the stratification process is clinical patient data, say an overwhelming 87 percent of respondents to the Healthcare Intelligence Network’s (HIN) inaugural survey on Stratifying High-Risk Patients. However, obtaining and verifying patient data remain major challenges for many respondents. Following are 10 more statistics from our survey.

  • „„Hospital readmissions is the metric most favorably impacted by risk stratification tools, according to a majority of respondents.
  • „„In addition to high utilization, clinical diagnosis is considered a key factor in stratifying high-risk patients, according to 16 percent of respondents.
  • „„Case management as a post-stratification intervention is offered by 83 percent of respondents; health coaching by 56 percent.
  • Reducing heart failure (HF), pneumonia (PN), and atrial myocardial infarction (AMI) are among the greatest successes of risk stratification programs.
  • Diabetes is considered the prominent health condition among high-risk populations, according to 37 percent of respondents; other prominent conditions include hypertension (20 percent) and mental health/psychological issues (15 percent).
  • Physician referrals are cited by 76 percent of respondents as an important input for stratification, followed by case/care manager referrals (71 percent).
  • „„Home health and/or home visits are available to risk-stratified populations of 56 percent of respondents.
  • „„LACE (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Nearly half of respondents (45 percent) cite high utilization of the emergency department (ED) or hospital as the most critical attribute of high-risk patients.
  • „„While more than half of respondents have a program in place to identify and risk-stratify complex cases, the majority admit it is too early to tell the ROI achieved.

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Stratifying-High-Risk-Patients_p_4963.html

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement — data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry’s value-focused climate.

Pioneer ACO Repurposes Care Management for Accountable Care

February 4th, 2014 by Jessica Fornarotto

As a top performer in Year 1 of the CMS Pioneer ACO program, Monarch HealthCare is paving the way to accountable care with a foundation of patient- and provider-centered strategies that support Triple Aim goals, which is to improve quality, improve health outcomes and reduce cost. Here, Colin LeClair, executive director of ACO for Monarch HealthCare, recounts how Monarch recast its Medicare Advantage (MA) care management program to target about 1,200 high-risk patients who have a similar constellation of issues.

Monarch repurposed our Medicare Advantage (MA) care management program for the ACO. Monarch’s ACO care management team was designed to anticipate and prevent acute events and then to facilitate transitions of care for patients post-discharge.

This interdisciplinary team is comprised of a primary care physician who quarterbacks the team, and a care navigator, also known as a care coordinator, who performs most of the patient onboarding into the care management program and performs an initial triage of the patient’s needs. The care manager is often a non-complex patient’s primary point of contact. The complex care manager is responsible for most of the complex cases.

Then as needed, we also deploy a behavioral health clinician, a community services coordinator, a clinic dietician and a palliative care nurse. The other resources may include a pharmacist or Pharm D to perform post-discharge medication reconciliation. Then we have a team of medical directors, employed and contracted hospitalists, and employed and contracted skilled nursing facilitators (SNFs) to support us as well.

The idea is that the team is tailored for the patient’s need at enrollment, and it can then be augmented as the patient’s health status changes. This model scales best when you can target large patient populations with a fairly common list of conditions, which allows you to hire and assign clinicians with the appropriate expertise to each patient. For example, we can afford to hire and assign a registered nurse (RN) or a nurse practitioner (NP) who has experience in a dialysis clinic or a nephrologist office if we have enough renal disease patients to fill their case load.

Excerpted from: Tactics from a Top-Performing Pioneer ACO: Engaging Patients and Providers in Accountable Care

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.

High-Risk Patient Roster Helps Atrius Pioneer ACO ‘Beat the Benchmark’

May 17th, 2013 by Patricia Donovan

Webinar Replay: Lessons from Atrius Health Pioneer ACO

They don’t call them pioneers for nothing.

A high-risk patient roster, a retooled geriatric care model and a preferred SNF network are just a few Atrius Health innovations on the healthcare frontier.

Atrius Health is one of 32 participants in the CMS Pioneer ACO program testing alternative payment and program design models for accountable care organizations. Emily Brower, Atrius Health executive director of accountable care programs, shared first-year lessons during a recent webinar, Medicare Pioneer ACO: Case Study on Atrius Health’s Focus on the Triple Aim.

Atrius was drawn to the three-year Pioneer ACO program for a number of reasons. First, it offered the non-profit alliance of six independent medical groups a chance to showcase its core competencies, including its rich data environment, foundation in the patient-centered medical home (PCMH) model and new home care services, Ms. Brower said.

Also, it gave the Massachusetts organization a chance to build a population-based approach to managing its Medicare population as a whole, with Triple Aim goals as a foundation.

And finally, they had a lot of faith in the staff of the CMS Center for Medicare/Medicaid Innovation, where the project resides. “We feel they really understand the issues we face in being accountable for care across the continuum,” noted Ms. Brower.

The Pioneer ACO shared savings and loss model challenges participants to perform against nationally identified trends. CMS take a participating ACO’s population and creates from the national Medicare database a reference population, she explained. “We’re trying to beat the trend in that national population, or ‘beat the benchmark.'”

In 2012, Atrius launched six clinical and technical initiatives to address the program’s 33 quality measures — “the gate through which the ACO achieves savings.” Key among them is its eight-step high-risk patient roster review, a hallmark of Atrius’s redesigned geriatric care model.

“We used a new risk stratification tool to identify our high-risk patients, who go on a roster reviewed by a multidisciplinary team in the primary care practice to identify care gaps, including a need for advance directives.” One outcome of the roster’s use has been an increase in end-of-life conversations, she says.

On the technical support side, Atrius Health developed new tools within its EPIC® electronic health record (EHR) for tracking quality efforts, advanced care planning, medication reconciliation and other key metrics.

Ms. Brower estimates the total investment to launch the ACO, including the EHR, quality measurement tools and other efforts, to be between $2 and $3 million; the medical groups themselves likely spent that much again for additional care management resources.

“In terms of payback, we expect that we will be able to reduce the cost of care — to bend the cost curve so that we are beating the benchmark and creating savings that then support our additional investments.”

Among programs on the drawing board: new ways to use the geriatric well visit, a home-based primary care program for high-risk patients, two programs for dual eligibles, and a patient advisory group.

Atrius Health is committed to the Pioneer ACO program, despite concerns from some participants over the program’s quality measurement process communicated to CMS last month. “We know it’s going to take time. As we would say, ‘We’re not called pioneers for nothing.’ It took us that first year to identify develop most of the tools and infrastructure that CMS needed.”

She continues: “The new measures that I mentioned that are coming out of the EHR being reported directly to CMS — that piece that we had to put together. There just wasn’t an existing pool of data to build benchmarks for those measures. Now that we have data, CMS will use this to create empirical benchmarks, which was one of the recommendations in that Pioneers communication.”

Listen to an audio interview with Atrius Health’s Emily Brower.