Risk Stratification of patients in Primary Care: Financial Movement

1. Risk Stratification of patients in Primary Care: Financial Movement Getting through the noise Justin J Villines, MBA, HCM University of Arkansas for Medical Sciences Center for Rural Health

2. Disclosures The following planners, speakers, moderators, and/or panelists of this CME activity have no relevant financial relationships with commercial interests to disclose: • Justin Villines, MBA,HCM

3. Evolution of primary care

4. Care Coordination:Our Care Venues…

5. Definition • Risk Stratification is a tool to assist in the identification of people who are at most risk of (re)admission to hospital.

6. Challenges • Lowering reimbursement reduces access and increases ER usage/costs • Reducing eligibility or benefits limited by federal “maintenance of effort”; raises burden of uninsured on community and providers • The highest cost patients are also the hardest to manage (disabled, mentally ill, etc.) ─ Risk Stratifying to address this challenge • Utilization control and clinical management only successful strategy to reining in costs overall

7. State-Wide Financial Effort • Statewide medical home and care management system is starting to be in place to address quality, utilization and cost • Medicaid savings in state, Comprehensive Primary Care Initiative (CPCi) • A Medicaid management solution that improves access and quality of care • Medicaid savings that are achieved in partnership with – rather than in opposition to – doctors, hospitals and other providers.

8. Improved Care • Improve the care of Medicaid, Medicare, and private payers population while controlling costs • A “medical home” for patients, emphasizing primary care • Community networks capable of managing recipient care • Local systems that improve management of chronic illness in both rural and urban settings

9. Wagner Chronic Care Model

10. Why is risk-stratified care management important? • The identification of a patient's health risk category is the first step towards planning, developing and implementing a personalized patient care plan by the care team, in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other providers, intensive care management, or collaboration with community resources.The goals are to help the patient achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to a higher risk category with higher costs.In a practice panel of 1,000 patients, there will likely be close to 200 patients (20%) who could benefit from an increased level of support. This top 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1% (via the Commonwealth Fund Issue Brief, May 2011).

11. Significant Risk Factors to Consider When Assigning a Patient’s Category or Score • Patient's health risks as identified by a health risk appraisal form or other questionnaire • Clinical diagnoses • Utilization data from insurer or other source • Clinician’s personal knowledge related to a patient’s social, financial, mental, or physical condition

12. Health Risk Categories • Primary Prevention (Level 1 and 2): Patients who are healthy and have no known chronic diseases could be assigned to a low risk category, or Level 1. Patients who are healthy but showing warning signs of potential health risks may be assigned to Level 2. Patients in the primary prevention category tend to be lower in their health care resource expenditures. • Secondary Prevention (Level 3 and 4): A patient who has a chronic disease, is managing it well, and meeting their desired goals, may be assigned to an intermediate category (Level 3). Those who are not in control of his/her disease but have not developed complications may be assigned to Level 4. Patients in the Secondary Prevention category tend to be moderate users of health care resources. • Tertiary Prevention (Level 5): If a patient's chronic disease has progressed, become unstable, or new conditions and/or significant complications have developed, they may progress to the tertiary category (Level 5). Patients in the tertiary prevention category usually rank high in health care resource expenditures. • Catastrophic (Level 6): An additional, non-public health Level 6 category is reserved for extreme situations, such as a pre-term baby who needs intensive long-term care, a patient who has a severe head injury, or anyone requiring highly complex treatment. Patients in the catastrophic category have extremely high health care resource expenditures and may be under the care of several sub-specialists. (AAFP, 2012)

13. Chronic Care Systems • Characteristics of High Performing Chronic Care Systems 1: • Universal coverage • Care free at the point of use • Delivery system should focus on prevention of ill health not just treatment of sickness • Priority should be given to patients to self manage their conditions with support from carers and families • Priority is given to primary health care • Population management is emphasised through the use of risk stratification tools and care planning • Care should be integrated – primary, community, social care, secondary care • Exploit the potential benefits of information technology in improving chronic disease • Care should be properly coordinated especially in those with multiple conditions including patient activation • Link the above 9 characteristics into a coherent whole to achieve cumulative impact 1 Chris Ham. The ten characteristics of the high-performing chronic care system. Health Economics, Policy and Law, 2010; 5(01); 1-20

14. Workflow in the real world… PATIENT

15. Workflow in the real world… PATIENT

16. Workflow in the real world… PATIENT

17. PATIENT

18. Have we made his life better?

19. Multiple Data Sources EMR data Practice data Inpatient data Social Services data Outpatient data Practice Combined Model

20. What to do? A loud ‘signal’ MUST be heard amidst the clinical ‘noise.’   • Technology must be targeted to the most appropriate patients: Risk stratification • Decision support must be integrated into the data flow process • Information must be reliably delivered to the correct team member (frequently not the primary care provider) • Clinically actionable signals should be sent to the primary care team member • Real time

23. Risk Stratification

24. Risk Stratification Cluster A Cluster B Cluster E Cluster C Cluster D

25. Risk Stratification Renal Disease, Depression, & CV risk Diabetes & CV risk Healthy Obesity & CV risk Complex, CV disease & Depressed

26. Static and Dynamic Components No static and no utilization* within 365 days Static variables only (no utilization) or no Static w/Util within 365 days Static and utilization history (days 31-365) or top 20% with no utilization within 365 days Static and util.(Top 20% risk with until <365 days) Immediate utilization within 30 days (regardless of static results) Immediate Intervention The risk strat model is to reduce the number of & .

27. Hypertension Healthy Obesity & CV risk Hyperlipidemia & Hypertension

28. Chronic lung disease, Depression & CV risk Diabetes & CV risk Complex, CV disease & Depressed Renal Disease, Depression, & CV risk

29. Cueing the team Delete Patient Data 1 2 Delete Patient Data Patient Data 3 Delete 4 Delete Patient Data

30. Cueing the team

31. Clinical Engagement • Risk Stratification tools are shown to work • Combined Predictive Model the most advanced • Significant savings and quality improvements • Our future Acute activity is predicated on achieving these savings • Progress– Clinical engagement

32. Summary • Primary care environment offers opportunities for technology to improve the quality of patient care • monitoring clinical conditions • coordination and transitions of care • medication management • But we have to be careful implementing technology in an occasionally chaotic environment – Primary care