Determination of Highest Risk Patients Adult Patients

1. Determination of Highest Risk Patients Adult Patients

2. 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.

3. 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??

4. Risk Stratification and Related Interventions Identify Patients with Asthma in Panel Determine Priority Patient Need Determine Delivery Mechanisms Patient F/U (PV) with Provider Low Risk Asthma – Intermittent Phone F/U Q 6 mos Asthma Clinic (Provider Present) Q X mo prn Parent Asthma Management Class Medium Risk Mild Persistent Asthma Medication Advanced Protocol Titration Upward Monitoring Care management Active Care Management Transition care Med Titration ? Home visit Q X weeks Advanced Medication Management Advanced Self-care Asthma Education Adolescent GV Parent Support Class Monitoring calls ER Follow-up Call High Risk Moderate or Severe Persistent asthma Pts in ER Pts Hospitalized Asthma Nurse Education Action Plan MS goal PRN Group Visits (Provider Present) Parent Education Child Education Social issues Transportation $$ for Meds Parental neglect Housing Social Worker

5. Risk Stratification and Related Interventions Identify Patients with DM in Panel Determine Priority Patient Need Determine Delivery Mode Determine Frequency of Patient F/U with Provider Lab q 3mo Phone F/U Low Risk Patients BP<130/80 A1c <7.0 LDL <100 Q 6 MO Disease Clinic (with Provider) Titration BG Monitoring BP Monitoring Lab q x mo KEY Low risk Medication Advanced Protocol Titration Upward Monitoring Medium Risk Patients BP>130/80 <140/90 A1c >7.0< 8.0 LDL>100<130 Medium risk All Risk per capacity) DM Class DM Education SMS goal High risk Advanced Self-care DM Education SM Support SM Class Monitoring Functional ability Highest risk Group Visits ( with Provider) DM Education SMS goal High Risk Patients BP>140/90 A1c>9.0 LDL>130 Social Worker Q X mo PRN Team management Monitoring (BG, SM Goal, BP) Phone follow-up Q X mo PRN • Highest Risk Patient • BP>210/140 • A1c>9.0 • LDL>200 • Pts in ER • Pts Hospitalized Social Support Transportation $$ for Visit, Meds, co-pays Abuse, etc. PRN as needed Care management Close Monitoring (BG, SM Goal, BP, BMI, etc.) Titration of meds Scheduled phone follow-up

6. Risk Criteria • Degree of Disease Severity • BP • A1c • LDL • Utilization Frequency • Office Visits • Phone calls to the office • ER visits • Hospitalization

7. Risk Criteria • Self-care Deficit • Taking of meds • Following diet • Activity • Social Issues Phone • Transportation issues • Lack of support at home • Lack of resources $$$$$

8. 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

9. PCP/Medical Home Site Collaboration • Direct referrals from PCP • Review high risk list with PCP’s • Medical Home support staff referrals

10. 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

11. Predictive Modeling

12. 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.

13. Questions?