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Central to success in value-based care (VBC) is risk stratification — a process that involves classifying patients based on various health indicators, medical histories, and non-medical risk factors including social determinants of health (SDOH). This categorization is crucial for developing interventions designed to address potential health issues pre-emptively with care coordination programs – plural. One size fit all care coordination will miss the individualization needed for success. Which programs needed for your practice will depend on analyzing the needs of your patient panel and who in your organization is best equipped to help manage these needs. Different billable services such as Principal Care Management (PCM), Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM) may be utilized but also structured disease specific programs such as cardiac, diabetes, and respiratory focused programming may best address the needs of your panel.
Staffing Model & Care Management Programs
The number of patients enrolled in a care management program should be determined by your staffing model. This may require hiring additional staff such as certified medical assistants (CMA) who are trained and supervised to provide this service. This can be more cost efficient than only using RNs and SWs. The ultimate goal would be enrolling 50% of the eligible population, knowing some patients will decline to participate and some will drop after a short period of time. Patient education about the care management programs during a provider visit is essential to patient understanding and participation and is a billable care management service requirement.
High-Risk Population Identification
Identification of high-risk population often tends to be reactive and focused on recent emergency department (ED) visits or inpatient (IP) admissions – the “shoot the wolf closest to the door” approach. While recent acute utilization is important to address with follow up primary care and specialist provider visits, it is best to have this be a part of a coordinated care approach. This approach uses billable or non-billable care management, care coordination, and risk stratification over more areas than acute utilization. Other risk factors that are key to the identification of the population in most need of care management and coordination of services include fragmented care risk, risk of high cost over a 24-month period, patients with a large medication count and gaps in refilling medications. Pharmacy management may not seem like the biggest concern, but between 12-14% of ED visits are related to adverse drug events (ADE). Additionally, between 25-30% of ED visits are related to medication events including underdose, overdose, and adverse drug interactions. Having a pharmacist involved in your care coordination can assist with medication review and deprescribing efforts. Care management and care coordination efforts for these populations can reduce IP and ED use and provide more proactive interventions to improve future outcomes and patient engagement.
SDOH Screenings
Another key area of focus for a care coordination is ensuring your care coordinators are comfortable performing screenings about SDOH and possess understanding of which areas need follow up interventions from community-based organizations (CBO) in your service area. These SDOH — including environmental conditions, socio-economic status, education, access to nutritional food options, and access to healthcare — play a monumental role in driving health outcomes. Estimates suggest these factors account for as much as 80 to 90% of health outcomes. Feeling comfortable with asking the questions in a culturally sensitive manner will increase the likelihood that patients will answer honestly without shame. Providing essential follow up referrals and coordinating with the CBO for service delivery must follow the assessment for the SDOH screenings to have any impact.
Care Management Solutions
Using a care management solution that easily identifies and stratifies patient risk in key areas is essential to the program’s success. Acclivity’s Care Management module includes SDOH identification, number of providers, medication counts and refill gaps. Identification of admit and readmit risk, total high spend over 24 months risk, and identification of chronic conditions from the patient’s claims history will allow for individualized programming. Acclivity uses the Johns Hopkins ACG system to allow for confidence in the predictive analytics and your risk stratification accuracy. With the correct risk stratification, assessments, and CMS tools, care coordination can be simple!
More information is available at the Acclivity website on our Value-Based Care and SDOH pages.
Author:
Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions
