determination of highest risk patients adult patients
TRANSCRIPT
Determination of Highest Risk Patients Adult Patients
Objectives
• Describe the “highest risk” patients; the top 5%of patients most at risk for hospitalization, ER visits, and sentinel events.
• Describe the key components of the highest risk registry.
Why risk stratify? • Identify patients with high problems – address priority needs .• Maintain access to care.• Prevent unnecessary transitions in care for the patient (ER
visits and hospitalizations) – prevent sentinel events. • Utilize limited practice resources effectively.• Decrease the utilization of resources downstream• Decrease the overall cost of care – shift resources to PCP • Other??
Identify Patients with Asthma in Panel
Low RiskAsthma – Intermittent
Medium RiskMild Persistent Asthma
High Risk Moderate or Severe Persistent asthma Pts in ERPts Hospitalized
Determine Priority Patient
Need
Medication Advanced Protocol Titration Upward Monitoring
Advanced Self-careAsthma EducationAdolescent GVParent Support ClassMonitoring callsER Follow-up Call
Social issuesTransportation$$ for MedsParental neglect Housing
Patient F/U (PV) with Provider
Determine
Delivery Mechanisms
Q 6 mosPhone F/U
Care managementActive Care Management Transition careMed Titration ?Home visit
Asthma Clinic (Provider Present)
Asthma NurseEducationAction Plan MS goal
Group Visits (Provider Present)Parent EducationChild Education
Social Worker
Advanced Medication Management
Q X weeks
Q X mo prn
PRN
Risk Stratification and Related Interventions
Parent Asthma Management Class
Identify Patients with DM in Panel
Low Risk PatientsBP<130/80A1c <7.0LDL <100
Medium Risk Patients BP>130/80 <140/90A1c >7.0< 8.0LDL>100<130
High Risk PatientsBP>140/90A1c>9.0LDL>130
Determine Priority Patient Need
Medication Advanced Protocol Titration Upward Monitoring
Advanced Self-careDM EducationSM SupportSM ClassMonitoringFunctional ability
Social SupportTransportation$$ for Visit, Meds, co-paysAbuse, etc.
Determine Frequency of Patient F/U with Provider
Determine Delivery Mode
Lab q 3mo Q 6 MOPhone F/U
Team managementMonitoring (BG, SM Goal, BP) Phone follow-up
Disease Clinic (with Provider)Titration BG MonitoringBP Monitoring
DM ClassDM EducationSMS goal
Group Visits ( with Provider)DM EducationSMS goal
Social Worker
Q X mo PRN
Q X mo PRN
PRN as needed
Risk Stratification and Related Interventions
Lab q x mo
Low risk
Medium risk
High risk
Highest risk
Highest Risk PatientBP>210/140A1c>9.0LDL>200 Pts in ER
Pts Hospitalized
Care managementClose Monitoring (BG, SM Goal, BP, BMI, etc.)Titration of medsScheduled phone follow-up
All Risk per capacity)
KEY
Risk Criteria
Degree of Disease Severity BP A1c LDL
Utilization Frequency Office Visits Phone calls to the office ER visits Hospitalization
Risk Criteria Self-care Deficit
Taking of meds Following diet Activity
Social Issues Phone Transportation issues Lack of support at home Lack of resources $$$$$
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Risk and Interventions Differentiation
• Team and Medium and High Risk Patients– Group Visits– Group Education– Follow-up care with
team
• CM and Highest Risk– Individual phone calls
to adjust insulin and review symptoms
– Specific patient action plan with hypoglycemic instructions
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PCP/Medical Home Site Collaboration
• Direct referrals from PCP• Review high risk list with PCP’s• Medical Home support staff referrals
Predictive Molding
• Predictive analytics is the branch of data mining concerned with the prediction of future probabilities and trends.
• An insurance company is likely to take into account potential driving safety predictors such as age, gender, and driving record when issuing car insurance policies.
• Multiple predictors are combined into a predictive model, which, when subjected to analysis, can be used to forecast future probabilities
Site#Forecasted Risk Index AIS CIS
Risk Rank Sex Age Total Paid
Forecasted Cost Primary ETG Group
Program Status as of
8/27/08
101 4.1 91 35 5 M 82 $42,187.00 $44,456.00Cerebrovascular Accident MHOpen
101 4 80 37 5 M 68 $46,972.00 $43,405.00Cardiovascular Surgery
Closed-Need met
101 6.21 100 28 5 M 67 $137,724.00 $67,387.00 Infectious Disease MHIdentified
101 3.19 93 25 5 F 75 $70,344.00 $34,563.00Degenerative Ortho disease
MHCL-Needs meet
101 4.53 94 60 5 M 81 $49,157.00 $49,173.00Cerebrovascular Accident
101 10.2 97 51 5 F 71 $133,870.00 $110,630.00Renal Failure, Chronic & Nephrosis MHOpen
101 5.59 90 62 5 M 81 $25,981.00 $60,613.00Renal Failure, Chronic & Nephrosis MHIdentified
102 8.87 95 50 5 F 79 $113,895.00 $96,235.00Renal Failure, Chronic & Nephrosis MHCL- CC
Predictive Modeling
Process for Determining Highest Risk Patients
• All patients that are post discharge are at high risk for readmission.
• Review all list with PCP to identify which patients need intervention or fit criteria for Complex Case Management.
Questions?
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