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November 2012 Webinar. Data Review Risk Stratification Working with Specialists. Data Review. How are we doing in each region?. Why Trending Wrong Way?. Things to Consider. Self management support Who are these patients? Have they been in recently? Depression screening?

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November 2012 webinar

November 2012 Webinar

Data Review

Risk Stratification

Working with Specialists

Data review

Data Review

How are we doing in each region?

Things to consider
Things to Consider

  • Self management support

  • Who are these patients?

  • Have they been in recently?

  • Depression screening?

  • Need to start insulin?

  • Diabetes educators

Wow how can we build on success
WOW! …How Can We Build on Success?

Ldl control tips
LDL Control Tips

  • Lowers risk of heart disease and STROKE

  • Can get non-fasting lipids

  • What % on statins vs. need to titrate more?

  • Most myalgias not from statin

Risk stratification

Risk Stratification

Key to Your Return on Investment

Why risk stratify
Why risk stratify?

  • Identify patients with highest needs – prioritize.

  • Utilize limited practice resources effectively.

    • Use to determine visit frequency.

    • Maintain access to care.

  • Biggest bang for the buck is to focus on high risk!

    • Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events.

    • Decrease the utilization of resources downstream.

  • Decrease the overall cost of care.

    • Shift resources to PCP.

Delivery system design
Delivery System Design

  • Define roles and distribute tasks among team members.

  • Give “planned care” at every visit — planned interactions that routinely use evidence-based care. (Team and MD/Provider Role)

  • Intensify patient medication if goals not reached —stepped care. (MD/Provider Role)

  • Follow-up care for medium/high risk patients. (MD/Provider and Team Role)

  • Care management intervention for highest risk patients. (Care Manager Role)

  • Give patient-centered care that patients understand and that fits their culture.

Care management
Care Management

  • Someone whose job is to work with high-risk patients.

  • Usually a nurse.

  • Who in your practice can do this?

    • Good people skills

    • Good listener

    • Problem solver

    • Empathetic

Decision support
Decision Support

  • Utilize standing orders for team members.

  • Use stepped care protocol for medications.

  • Integrate specialist expertise and primary care.

  • Complete risk assessment at every visit.

Bottom line you are trying to identify your sickest 5 10


Risk criteria
Risk Criteria

  • Degree of Disease Severity-


    • BP

    • A1c

    • LDL

Other factors to consider
Other Factors to Consider

  • Utilization Frequency

    • Office Visits

    • Phone calls to the office

    • ER visits

    • Hospitalization

  • Self-care Deficit

    • Taking of meds

    • Following diet

    • Activity

  • Social Issues

    • Phone

    • Transportation issues

    • Lack of support at home

    • Lack of resources $$$$$

High risk patient categories
High Risk Patient Categories

  • Patients with hospital admissions and ER visits.

  • Patients with co-morbidities.

  • Patients with depression.

  • Patients with functional or cognitive issues.

  • Patients who have high utilization rates for office services(e.g., frequent visits, phone calls).

Looking at y our highest risk
Looking at Your Highest Risk

  • A1C >9?

  • LDL >130?

  • BP >160/95?

  • Calculate how many you have?

  • Maybe you need to start even higher.

  • Have they been seen in last 6 months?


  • What can be done different?


November 2012 webinar


TE P 4

Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention


Getting Medium and High Patients in for Follow-up Visits

Step-wise Approach to Risk and Intervention Stratification


Giving DM Planned Care at Every Visit




Building Registry Functionality for Patients with DM

A few risk stratification tools ninth street internal medicine birdsboro family medicine
A Few Risk Stratification Tools Ninth Street Internal Medicine Birdsboro Family Medicine

Ncqa requires risk stratification and care management

NCQA Requires Risk Stratification and Care Management

PCMH 3: Plan and Manage Care

Pcmh 3 plan and manage care
PCMH 3: Plan and Manage Care

  • Element B: Identify High-Risk Patients

    • Factor 1: Establish criteria and a systematic process to identify high-risk or complex patients.

      • High resource use (visits, medications, costs)

      • Frequent urgent care/ER visits (2+ in 6 months)

      • Frequent hospitalizations

      • Multiple comorbidities

      • Noncompliance with prescribed treatment, meds

      • Terminal illness

      • Psychosocial issues (social, financial support)

      • Advanced age, frailty

      • Multiple risk factors

Pcmh 3 plan and manage care1
PCMH 3: Plan and Manage Care

  • Element B: Identify High-Risk Patients

    • Factor 2: Determine the percentage of high-risk or complex patients in your patient population.

      • Must show criteria and process for selecting.

      • Must provide report showing numerator/denominator and percentage of high-risk or complex patients.

Pcmh 3 plan and manage care2
PCMH 3: Plan and Manage Care

  • Element C: Care Management [MUST PASS!]

    • Based on sample of high-risk patients identified.

    • Must:

      • Do pre-visit planning.

      • Develop individual care plans and review/update at each visit.

      • Give patients written plan of care.

      • Assess and address barriers when goals not met.

      • Give patients clinical summary at each visit.

      • Identify and refer patients to community resources.

      • Follow up with missed appointments.

Working with specialists

Working with Specialists

It’s All About Communications!


  • 62% of PCPs report getting consults from specialists.

  • 81% of specialists report sending info to PCP.

  • Lack of clarity of respective roles.

  • 69% PCPs provide history and reason for consult ‘always’ or ‘most of the time.’


  • Referral: transfer of care

  • Consultation: one-time or limited time

  • Collaboration: ongoing co-management

Using consultants effectively
Using Consultants Effectively

  • When to consult:

    • Trouble making a diagnosis

    • Specialized treatment

    • Goals of therapy not met

  • Make your consultants partners

    • 1st principle of partnership - communication

    • Communication begins with you

    • Ask a specific question

    • Specify type of consult: ongoing (referral), one time only, duration of specific problem

Adapted from material by Steve Simpson, MD, at Kansas University.

November 2012 webinar

Example of an Agreement: Primary Care Side

Primary Care

State that you are requesting a consultation.

The reason for the consultation and/or question(s) you would like answered.

List of any current or past pertinent medications.

Any work-up and results that has been done so far.

Your thought process in deciding to request a consult.

What you would like the specialist to do.

Source: HealthPartners, MN

November 2012 webinar

The Specialty Side

Specialty Care

State that you are returning the patient to primary care for follow-up in response to their consult request.

What you did for the patient and the results.

Answers to Primary Care Physician questions in their consult request.

Your thought process in arriving at your answers.

Recommendations for the Primary Care Physician and educational notes as appropriate.

When or under what circumstances the Primary Care Physician should consider sending the patient back to you.

Source: HealthPartners, MN

Upcoming meetings
Upcoming Meetings

  • December Webinar

    • Thursday, December 20: 12-1pm

    • PDSA Sharing and some fun;)

  • January Learning Sessions

    • South Central: Tuesday, January 22

      5-9pm, Penn State Hershey Conference Center

    • Northwest: Tuesday, January 29

      5-9pm, Location TBA

Here to help you
Here to help you!

  • South Central – Sharon Adams


  • North West – Patty Stubber