The importance of risk stratification and pop health in value-based care

These two essential capabilities must be harmonized to better segment populations to tailor care, enabling personalized patient care.

The healthcare industry is at a crossroads, with value-based care emerging as the new paradigm shaping the future of patient treatment and healthcare economics.

In the next five years, research suggests continued uptick – almost double – in the adoption of value-based payment models, a trend that reflects the sector's commitment to evolving beyond traditional fee-for-service frameworks. This transition, further accelerated by the COVID-19 pandemic, has highlighted the critical importance of aligning financial incentives with patient health outcomes, ensuring that the quality of care supersedes the quantity of services provided.

Central to this transformation is the acknowledgment and integration of social determinants of health (SDOH). These factors — environmental conditions, socio-economic status, education and access to healthcare — play a substantial role in shaping health outcomes, with estimates suggesting they account for as much as 80 percent to 90 percent of health outcomes. The healthcare industry is increasingly focusing on SDOH to enhance patient engagement and dismantle longstanding barriers to care, fostering a more equitable and effective healthcare system.

In response to these shifts, healthcare systems are pivoting towards the utilization of advanced technologies that offer flexibility and adaptability. These technologies enable the delivery of high-quality care while simultaneously managing and optimizing costs. The demand for such agile solutions is at an all-time high, with the rapid pace of change in healthcare necessitating tools and strategies that can keep up with the sector's complex and ever-evolving demands.

Advancing risk stratification

Risk stratification has become a critical component within the value-based care framework, as an essential strategy for enhancing community health outcomes. By leveraging the rich data contained within electronic health records, healthcare providers can gain deeper insights into patient health trends and outcomes.

Despite the promise of this approach, it has its challenges. Healthcare providers often encounter obstacles in the form of data integration issues, which can create gaps in patient insights.

To overcome these barriers, cutting-edge, vendor-neutral solutions are being developed and implemented to maximize the potential of strategic data integration.

At the heart of value-based care lies risk stratification — a process that involves classifying patients based on various health indicators and their medical histories. This categorization is crucial for developing personalized healthcare interventions designed to address potential health issues pre-emptively.

The healthcare industry's pursuit of precision in patient categorization is unwavering, with continuous efforts being made to refine patient data accuracy through sophisticated computational models.

A multi-layered approach

The importance of a robust population health management system is underscored by research from firms like Gartner, which advocate for a comprehensive risk stratification framework. Such a framework requires a detailed approach to patient categorization, classifying individuals into distinct risk categories based on their potential for clinical complications.

This process is complex, necessitating not only access to objective data but also the deep involvement of healthcare providers who possess a thorough understanding of their patient's unique health situations.

  • Clinical assessment. This involves a thorough compilation and analysis of patient data, which includes evaluating health conditions, reviewing health indicators and considering historical health information.
  • Social health analysis. An assessment of the patient's social and environmental factors is conducted to tailor interventions for those significantly affected by SDOH.
  • Consumer health preferences. Patients' preferences regarding digital vs. traditional healthcare delivery methods are considered, ensuring that the provision of care is personalized and patient centric.

Reforming patient management

The advent of value-based care has catalyzed a reformation in patient management strategies. Healthcare providers now incorporate a broader array of factors into their care plans, including SDOH and individual patient preferences regarding healthcare engagement.

This refined approach has led to the development of targeted healthcare strategies that are informed by the stratification of patients into specific groups based on their unique needs and circumstances.

These strategies include:

  • Specialist referrals. Ensuring patients with specific medical needs, particularly those highlighted by SDOH evaluations, receive timely access to specialized care.
  • Coordinated care models. Customizing care experiences to align with patient preferences, whether they favor digital platforms or traditional in-person services.
  • Personalized scheduling. Adapting appointment scheduling to reflect individual patients' risk assessments and preferences, thereby enhancing the overall patient experience.
  • Informed resource distribution. Allocating healthcare resources efficiently by combining medical insights with consumer preferences, thus optimizing both patient care and cost management.

Pioneering future models

As the healthcare landscape continues to evolve, industry leaders are steadfastly promoting the transition to value-based care. An unwavering focus on risk stratification is central to this transition because it enables healthcare providers to enhance management practices and optimize the use of resources.

Proficiency in both population health and risk stratification is becoming increasingly crucial as the industry addresses the challenges of refining risk assessments, improving patient interactions and adhering to evolving standards.

Kevin Riley is CEO and president of Zyter|TruCare.

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