Improving Patient Outcomes with Data

1. Improving Patient Outcomes with Data IPHCA PCA Wide Risk Stratification Understanding the Predictive and Pragmatic Use of Risk forPopulation Health Management August 8, 2018

2. Topics azarahealthcare.com

3. Risk – Risky – Riskier – Riskiest azarahealthcare.com

4. Feels Less Risky with Good Tools azarahealthcare.com

5. Value Why are risk stratification tools valuable for CHCs? azarahealthcare.com

6. The Value of a PCA Wide Risk Algorithm FOCUS • Identify Patients for Care Coordination • Needy • Costly • Coordination. • Target Focus • Patient Stratification • Supports • NCQA PCMH Requirements • Population Health Management • Patient Stratification • Care Management and Support • Primary Care Health Home • Community Health Worker • Focus precious care coordination resources on most needy and costly. • Standard algorithm to apply across multiple sights. • Economies of scale – cost and implementation

7. Can We Afford It? https://catalyst.nejm.org/opportunities-risk-based-primary-care-providers/ Chronic Pain as a Driver of Cost in ACO Arrangements. Rushakoff, BS et al. The American Journal of Accountable Care. 2018;6(1):29-32 azarahealthcare.com Practices that succeed at making the shift from fee-for-service to managing risk are routinely able to increase their practice profitability by at least 25%. 

8. Traditional Transactional Care Assumes you treat all patients the same Will not lead to success azarahealthcare.com

9. Population Driven Care Highly Complex <5% Clinical Care Management High Risk 5-10% Clinical Care Management/Coordination Goal is to segment patients and identify interventions that are appropriate to their needs. No more than 5% of patients should be high risk. Rising Risk 10-20% Care Coordination Low Risk 80% Prevention Monitoring azarahealthcare.com

10. Highly Complex Highly Complex <5% Clinical Care Management Multiple complex illnesses, psychosocial concerns/barriers. Requires intensive, proactive care management. Goal: Improve health outcomes and prevent high cost emergency or acute care services. azarahealthcare.com

11. High Risk High Risk 5-10% Clinical Care Management/Coordination Multiple risk factors that can lead to highly complex. Requires structured care management to manage medical, social and community needs. Goal: Improve health outcomes and prevention. azarahealthcare.com

12. Rising Risk One or several chronic conditions or risk factors with variable control. Goal: Manage risk factors that influence conditions. Rising Risk 10-20% Care Coordination azarahealthcare.com

13. Population Driven Care Minor conditions that are easily managed. Goal: Keep them healthy and engaged. Low Risk 80% Prevention Monitoring azarahealthcare.com

14. Top Spenders Not What We Thought….. azarahealthcare.com

15. Top Spenders Not What We Thought….. ” Simply put, three out of five top spenders in any given year were not top spenders in the prior year. azarahealthcare.com

16. Risk Algorithms Predictive vs Pragmatic azarahealthcare.com

17. Types of Risk Algorithms azarahealthcare.com

18. Risk Stratification Methods azarahealthcare.com

19. What Does Azara Offer? • Azara Risk Stratification • Johns Hopkins Adjusted Clinical Groups (ACG) • EHR documented risk score i.e., manual, ACO etc. EHR Data • Conditions • Clinical Values • Social Determinants Claims Data • Professional • Institutional • Pharmacy azarahealthcare.com

20. Defining Your Risk Algorithm azarahealthcare.com

21. Building the DRVS Risk Algorithm • Intentional process • Identifies patients with high degree of complexity. • Enables the center to provide the right level of care, services and interventions to those who can most benefit. • What are you looking to change? • Data source is your EHR • Primary – EHR clinical and administrative data • Secondary – Payer and HIE (Inpatient • and Emergency). • Groups individuals by High-Med-Low risk. azarahealthcare.com

22. Requirements for a Successful Implementation Why is this important to the organization? Who and how will you determine risk? How will risk be utilized? azarahealthcare.com

23. IPHCA Risk Development and Validation azarahealthcare.com

24. IPHCA Risk Development Committee Azara Proprietary & Confidential

25. Components of Your Risk Algorithm • Behavioral Health Disorders • Substance Use • Insurance Coverage • Language azarahealthcare.com

26. Risk Information In DRVS Risk Registry • Patients by criteria • Clinical override • Core Registry columns: Usual Provider, SDOH, Care Manager Reports • Patient Visit Planning • Risk level • Care Manager • Care Management Passport –risk over time Risk Dashboard • Patient counts • Risk distribution Risk Filter • Available across application • Used in favorites azarahealthcare.com

27. From Your Peers…. Why did I want to be involved? How are or are you planning to use risk at your center? What was important to your center to be included in the algorithm? azarahealthcare.com

28. Risk Documentation in DRVS HELP azarahealthcare.com Search for ‘risk’ in the Help Section of DRVS

29. azarahealthcare.com

30. Next Steps • Familiarize yourself with Risk tools DRVS. • Open the risk registry. • Export and have one or two providers or a care manager look at their patients. • Think about how you can use Risk to meet your quality and population management goals. • What programs will it support? • Who should use it? • What training do you need? • Attend the IQIN Face to Face Meeting on October 4, 2018. azarahealthcare.com

31. Questions?