Risk Stratification in Population Health Management a… · •How clinical risk stratification can...

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Risk Stratification in Population Health Management

Prepared by: Shannon Nielson, MHA, PCMH-CCE

Principal Owner/Consultant

CURIS Consultingwww.curis-consulting.com

http://www.curisconsulting.com/


Objectives

• How clinical risk stratification can impact your panel sizes, scheduling availability and external care coordination processes

• Strategies to risk stratify your patient population (HIT and manual)


Risk Stratification

• A tool for identifying-and predicting-which patients are at high risk-or likely to be at high ris-and prioritizing the management of their care. (mhpcommunity.org)

• Enables providers to identify the right level of care and servicesfor distinct subgroups of patients. It is the process of assigning a risk status to a patient and then using this information to direct care improve overall health outcomes. (NACHC)

• “It represents a move from a reactive single physician to a more proactive team to address the total health needs of the total patient population” (Asaf Bitton, MD- Center for Primary Care at Harvard Medial School)


Risk Stratification Process

• Predict• Who is at risk?

• Cost, quality and experience

• Prioritize• Management of those at risk

• Alignment of resources

• Prevent• Poor or worse outcomes

• The plateau of performance


Step Approach to Risk Stratification1

1. Better data means a better process

2. The patient’s voice and the clinician’s judgement are both essential

3. Start where you are

4. Know your patient (empanelment)

5. Know why you stratify

6. Risk is dynamic, not static

7. Risk Stratification and panel management demand and foster workflow redesign

8. Data alone is a start, not an endpoint; transformation requires action

9. Risk stratification is the way of the future


1. Better Data Means a Better Process

• Necessary Clinical & Practice Management Data?• Clinical Information (ie: Lab Results,

Health Maintenance info)• Visit/Encounter Data• Demographic Data (ie: zip code)• Payer Data (ie: Health Plan, Managed

Care, FFS, etc)

• Claims Data & Member Rosters (Attribution Files)?• Define Population• Visualize Care Gaps• Cost of Care• Pharmacy/Refill Data

• Consumable & Actionable Data• Can your system ingest, filter, and use

the data meaningfully?• Is the data normalized?

• Registries/Population Lists Based on Specific Criteria

• Risk Stratification Tool• Is Risk defined for your population

and is it measurable?

• Pre & Post-Visit Planning Processes


2. Patient Voice and Clinician’s Judgement

Patient Voice

• How does the patient stratify their health?

• What does the patient feel theyare at risk for? (cost, quality,experience)

• What is the most important factor in the patient’s health?

Clinician Judgement

• Who would you not be surprised to see in the ER?

• Who are your patients that would benefit from our additional clinical resources?

• Who is currently at risk of becoming high risk?


3. Start Where you Are

• What are your resources?• Data

• HIT

• Maintenance

• Skills/Training


Rick Stratification Tools

Risk Stratification Models:• Framingham Risk Score

• Adjusted Clinical Groups (ACGs)

• Hierarchical Condition Categories (HCCs)

• Elder Risk Assessment

• Chronic Comorbidity County

• Charlson Comorbidity Index

• Minnesota Health Care Home Tiering

Systems for Risk Stratification:• Conifer

• Evolent Health

• I2i Systems

• Mediquire

• IBM (Phytel)

• Wellcentive

• Explorys (IBM)

• RxPredict (not rated by KLAS but does use predictive modeling and interfaces with NextGen)

• ** Most EMRs offer a Population Health Solution or some sort of Risk Stratification as well


4. Know your Patient (Empanelment)

• Empanelment: Linking each patient with a responsible primary care provider. (AC13)• Goal= 100%

• Continuous cycle

• Patient agrees with assignment

• Provider does not exceed capacity

• Attribution: Assignment of a patient to a provider team (AC14)• Goal = 80-90%

• Foundation from which empanelment is built


Empanelment-Cont.

• Who do you take care of?

• When do you take care of them?

• How do you take care of them?

• What are the needs of your patients?


Empanelment- Measuring Capacity

PROVIDER NAME

A.

Total number of encounters for the past two years

NOTE: Do not count nurse-only visits

Unduplicated Patients

B.Number of unduplicated patients seen in the last year

C.Number of unduplicated patients seen in the year prior to last year

D.Number of unduplicated patients seen in the last two years

E.Number of new unduplicated patients seen last year

Average Visits per Patient per Year

F.

Calculate: [A / D] = AVPY

(Total number of encounters for the past two years / Number of unduplicated patients

seen in the last two years ) = Average Visits per Patient per Year #DIV/0!

Appointment Availability

G.

Length of appointment slots (in minutes)

NOTE: If your practice/clinic has more than one appointment slot

H.Number of appointment slots available on the schedule last year

Practice site/clinic: (insert name) Provider: (insert name)

FORMULA RESULT

DEMAND

Appointment needs of current populationB X F

Number of unduplicated patients seen in the last year

X Average Visits per Patient per Year #DIV/0!SUPPLY

Provider availabilityH

Number of appointment slots available on the schedule

last year 0RIGHT PANEL SIZE

The number of patients the provider can support

based on current availability

H / F

Number of appointment slots available on the schedule

last year / Average Visits per Patient per Year #DIV/0!

%GROWTH

[B – C] ÷ C

(Number of unduplicated patients seen in the last year-

Number of unduplicated patients seen in the year prior #DIV/0!


Empanelment-4 Cut Methodology

Cut Description PCP Assignment

1st Cut Patients who have seen only one provider in the past year

Assigned to that provider

2nd Cut Patients who have seen multiple providers but one provider the majority of the time in the past year- Plurality

Assigned to the majority provider

3rd Cut Patients who have seen two or more providers equally in the past year (No majority provider can be determined)

Assigned to the provider who performed the last physical exam

4th Cut Patients who have seen multiple providers Assigned to the last provider seen

(The Zero Cut) Patients who are empaneled to provider by have not been seen in 3 years

Patients who are empaneled to a provider no longer in the system

(No assignment)

(4Cut methodology or based on capacity)


5. Know Why you Stratify

Cost: (TOC, Multiple access points, medication volume etc…)

Quality: (Clinical outcomes, experience, engagement)

Support: (Community resources, SDoH, Care Coordination)


6. Risk is Dynamic

• Monitor your panels by size…• Also monitor your panels by risk

• Payer data isn’t real time…• But a patient’s clinical indicators are

• Social Determinants of Health are critical to understand…• As patients’ physical, environmental and social situations change

• A provider’s panel capacity is set…• And can change as risk of their panel changes

• Your staffing should be appropriate to manage panels…• And should change as your patient needs change


7. Risk Stratification Demands and Fosters Workflow Redesign• Distribution of workload

• Peak of Scope

• Priority Workflows


Distribution of Workload


Peak of Scope

Intensity of Risk

Inte

nsi

ty o

f To

uch

Practice Based

Clinical Team

Practice Based

Clinical Team

Care Management

Team

PHM Team/Care

Coordination

PHM Team/Care

Coordination

Care Coordination Team

PHM/Care coordination

Team

PHM/Care Coordination

Team

Practice Based Clinical Team

Practice Based

Clinical Team

Care Management

Team


Role InterventionsTransitions in Care Chronic Stable Hospital Admissions Chronic

Unstable/SDoHBH

Practice Based Clinical Care Team

Practice Based Clinical Care Team

RN RN/Care Management Team

BH Care Manager/LISW

Health Education Chronic Disease Management

Risk Assessment/Comprehensive Evaluation

High Risk Nursing Assessments

Psychosocial Assessments

Gap Closure Goal Setting Medication Review Physical Barriers to Care BH Intervention

Goal Setting Lifestyle Modification Rx Renewals Goal Setting MH Community Resources

Life Style Modification Gap Closure Motivational Interviewing Medication Review Shared Care Plans

Post Acute Discharge Care Planning

Disease Focus Evaluation Goal Setting Patient Centered Care Plan Development

Referral Management

Redirection to Primary Care

Self Management/PCP Utilization

Disease Management Chronic Disease Management/Reduce Cost

BH/PCP Coordination

Population

Role

Interventions

Care Coordination Focus


Role Scalability

Transitions in Care

Chronic Stable Hospital Admissions

Chronic Unstable/SDoH

BH

Pt. Identification 2 or more ED visits or ED Visit with new condition

2 or more chronic conditions or 1 new condition

Disease related hospital admission

2 or more chronic conditions with min. 1 unstable

1 or more BH Diagnosis

Role PHM Team/Practice Based Clinical Team

PHM Team/Practice Based Clinical Team

RN RN/Care Management Team

BH Team/LISW


Priority WorkflowsPriority Concern Process HIT Workflow Staff-Patient Workflow

ER Utilization Post discharge appointments and support

(ex. ER notification, schedule templates, Portal education)

(ex. RN follow up, scheduling within 5 days, 1 week follow up post visit)

New Diagnoses of DM Pre-Diabetic Monitoring and Support

Depression Management BH Referral process


8. Data is a Start, Not an Endpoint

• Patient oriented interventions• Shared Decision Making

• Motivational Interviewing

• Self Management Support Technology

• Patient awareness of care team

• We impact the patient which then impacts the risk score!• We don’t try to impact the risk score!


9. Risk Stratification if the Future

Efficiency EffectivenessQuality

(CostClinical Outcomes

Experience)

Quality(Cost

Clinical OutcomesExperience)

ImpactValue

(Payer, Patient, Practice, Provider)


Risk Stratification Impact

• Access• Panel Size: 3NA: Continuity

• Care Team Model• Relevant skills and people• Cost effective and efficient care opportunities

• Patient Experience• Relevance and Importance• “I feel like my provider understands my needs and wants”

• Provider Experience• “Informed” productivity• Care Team Utilization

• Staff Experience• Utilization of skill set• Witness to quantitative success (no more Ground Hogs Day)


Thank You!Shannon Nielson, MHA, PCMH-CCE

Principal Consultant

CURIS Consulting

[email protected]

513-260-9392

Date post:	22-Sep-2020
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