Throughout my 22 years in the healthcare technology space, including the last seven in value-based care, I have found that there are a few core strategies that can be deployed to better engage and manage high-risk or high-cost patient cohorts. Focusing care initiatives around these patient groups create impactful outcomes that are clinical and financial in nature. All successful population health endeavors begin with identifying groups of patients where there appear to be opportunities to intervene with care in a way that would close care gaps, reduce unnecessary utilization, help patients better manage a condition or benefit from a preventative type visit. The cohorts I mentioned earlier include patients:
- With comorbidities
- Who are past due for preventative services
- Who visit the ER frequently
- Who are amid care transitions
For one of the final blog posts in 2019, the expression “tried and true” comes to mind, which tends to be the opposite mindset before a new year. The following are core strategies healthcare organizations can utilize to focus care on the patient groups listed above to impact health outcomes for the better.
Vary Means of Patient Engagement
At Lightbeam, our advisors have an expression they frequently use when working with clients: “focus on your three.” What they are referencing is the top three percent of patients who are responsible for the highest resource utilization (usually around 66% of the total spend). The visual below represents the cost of complex care in a population. For the majority of your population, you will likely focus on preventative health, which encompasses primary care and services like Annual Wellness Visits (AWVs) aimed to catch any potential issues before they develop or exacerbate. In the value-based care mindset, preventative health helps avoid costly, potentially traumatic episodes for the patient. The next group will focus on disease management, which encompasses patients battling and managing a single chronic condition. Comprehensive care management is for patients who are in critical condition and whose conditions require immediate attention when something goes wrong. Finally, complex care is at the very top, the three percent. These are patients with multiple conditions and complex social determinants. Such patients will require the highest level of care intensity, but provide the most opportunity to impact health outcomes and reduce resource utilization.
Our suggestions for high-risk, high-cost patients:
- Stratify patients by their common needs and levels of risk.
- Keep the full patient picture in mind; their needs are more than physical. Many have social determinants of health (SDoH), such as behavioral and social factors that become barriers to treat their conditions.
- Shift care from an institutional standpoint to one of community. In the end, the work that caregivers provide is to offer support and to ensure patients are receiving the quality care promised in population health initiatives.
Devise Comprehensive Care Management Strategies
Care management is where the rubber meets the road. This is the patient-centered core of value-based care efforts. Regardless of the amount of risk and generated shared savings, the organization’s final quality score determines whether or not they can qualify to receive those earnings. The score exemplifies their efforts to improve the patient experience and delivery of care.
Tailored care management programs that are organization-specific and indicate careful research is how to manage patients that need additional oversight. Organizations that offer care management solutions or services need to do the legwork ahead of time to learn their clients’ current care management structures, what works for them, what remains a barrier for success, and their ultimate desired outcomes. From there, an organization like Lightbeam can gauge the next steps for training existing care managers or putting additional resources in place as a care team extension. Care managers provide accountability, support, and ensure that patients are fulfilling their treatment plans; their actions lead to positive results in both the peoples’ lives and in take-home savings at the end of each performance year.
Vary Means of Patient Engagement
Engaging the patient successfully with a constructed care plan is how Medicare patients know they need to schedule their AWV, keeps comorbid patients in check, keeps high-utilizers out of the ER, and prevents hospital readmissions. The questions we always ask at Lightbeam are:
- What care gaps, coding gaps, and fee-for-service opportunities exist?
- During an in-office visit, how can we ensure that the provider has all the information they need to treat this patient based on their history, insurance goals, and current care plan?
The effectiveness of a patient engagement campaign largely depends on the person’s familiarity with technology and their willingness to act on instruction. Phone calls, email reminders, text messaging, and voice messaging to confirm appointments, ensure medication adherence, and other functions keep willing beneficiaries in line with their care plans and preventative visits. The introduction of Lightbeam’s Patient Face Sheet in the exam room has substantially helped physicians make the most of their limited time with a patient, ask the right questions, and diagnose more effectively, having the whole picture in hand.
2020 is fast approaching, and while the new year often brings an “out with the old” mentality, my colleagues at Lightbeam and I know that honing our solutions that enable stratifying patients, care management, and patient engagement (to name a few) is what leads to continued success in value-based contracts for our clients.