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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
*All documents are property of CURIS Consulting. Do not duplicate or distribute without written permission.
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)
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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)
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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
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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
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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
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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?
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3. Start Where you Are
• What are your resources?• Data
• HIT
• Maintenance
• Skills/Training
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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
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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
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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?
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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!
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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)
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5. Know Why you Stratify
Cost: (TOC, Multiple access points, medication volume etc…)
Quality: (Clinical outcomes, experience, engagement)
Support: (Community resources, SDoH, Care Coordination)
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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
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7. Risk Stratification Demands and Fosters Workflow Redesign• Distribution of workload
• Peak of Scope
• Priority Workflows
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Distribution of Workload
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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
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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
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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
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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
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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!
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9. Risk Stratification if the Future
Efficiency EffectivenessQuality
(CostClinical Outcomes
Experience)
Quality(Cost
Clinical OutcomesExperience)
ImpactValue
(Payer, Patient, Practice, Provider)
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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)
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Thank You!Shannon Nielson, MHA, PCMH-CCE
Principal Consultant
CURIS Consulting
513-260-9392