Determination of Highest Risk Patients Adult Patients

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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