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Risk Assessment and Stratification

Risk Assessment and Stratification. Identifying Highest Risk Patients and Developing Interventions for Them. Identify Your Sickest Patients. Right now make a list of the 5-10 patients that worry you the most. name name name name name Are your lists the same as your co-workers?

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Risk Assessment and Stratification

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  1. Risk Assessment and Stratification Identifying Highest Risk Patients and Developing Interventions for Them

  2. Identify Your Sickest Patients • Right now make a list of the 5-10 patients that worry you the most. • name • name • name • name • name • Are your lists the same as your co-workers? • Why are these patients on your list? • What can you (provider and care team) do to improve things for each of these patients? • name • name • name • name • name

  3. Systematically Do That • What would happen if you made these lists every week or every two weeks? • Who in your office would be responsible for following up with these patients? • How would you carve out time for these staff to do this follow-up? • How would you document the follow-up care?

  4. How Might This Work Daily? • What criteria would you use to classify a patient as high-risk during an office visit? • How might you address the needs of patients you identify as high-risk during office visits? • How can you find out which patients are in the hospital and are being discharged each day? • How can you find out which patients have been in the ER in the past day or two?

  5. 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.

  6. Risk Factors to Consider • Degree of Disease Severity • Pick a number for BP, A1C, LDL, etc. • 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 $$$$$

  7. Looking at Your Highest Risk • A1C >9? • LDL >130? • BP >160/95? • Calculate how many you have? • Maybe you need to start even higher • Looking for the worst 5-10%

  8. Looking at Your Highest Risk • Have they been seen in last 6 months? • Bring them in! • What can be done different? • Self-Management Support! • Depression?

  9. S TE P 4 Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention STEP 3 Getting Medium and High Patients in for Follow-up Visits Step-wise Approach to Risk and Intervention Stratification STEP 2 Giving DM Planned Care at Every Visit STE P 1 Building Registry Functionality for Patients with DM

  10. Questions?

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