With penalties for readmissions, risk-based payment models, and new mandates to measure and improve community health, it’s more important than it’s ever been to identify high-risk patients before they show up in the ED. Boston’s Steward Health Care Network, one of Medicare's 33 Pioneer ACOs, has been using a combination of claims and clinical data, sophisticated analytics, and the gut feelings of its physicians to stratify its patient population and target certain layers for special interventions. Vice President of Population Health Dominique Morgan-Solomon will share some of the organization’s secrets during a HIMSS14 presentation titled “Data-Driven: A Pioneer ACO Applies Data to Improve Patient Care” on Monday, Feb. 24 at 11:30 a.m. -12:30 p.m.  

“There’s a misperception that you need to focus all your efforts and resources on the top one or five or ten percent [of high-cost patients] to manage your costs,” she says. “In theory it makes sense, but if you dig into population level data you find that the top five percent is things you couldn’t have managed, like cancer or a car accident. Those people aren’t going to stay at that level from a cost perspective.”

Instead, she and her team look for patients with certain characteristics that predict repeated and possibly escalating episodes of care. For example, a diabetic woman who is also depressed might neglect her daily diet, exercise and medication regimen, and miss screenings that would catch high sugar levels, foot sores, or eye problems.  If she’s flagged for extra interventions, she might be assigned a case manager and a social worker to keep her on track with her diabetes care plan and also treat her depression so that she can eventually take care of herself without the extra help.

“That’s a lot of resources, but to prevent even one hospitalization for dehydration, the investment makes sense for us,” Morgan-Solomon says

During the session, she’ll:

  • Describe how clinical data is being tied to financial data to determine success for organizations participating in accountable care models
  • Explore the tools necessary to collect, measure and report on clinical effectiveness and outcomes
  • Discuss how providing access to individual metrics can help Steward's clinicians improve the quality and cost of care the organization provides

Morgan-Solomon’s focus will be on identifying actionable data. While much of it is in various databases, a key part is in the brains of primary care physicians.
“Physicians can tell you their ‘top ten,’ and they’re not necessarily the ones that the numbers will show,” she says. The care management team uses concrete data to identify a physician’s highest risk patients, but finalizes the intervention list based on the physician’s feedback. “We ask, ‘If I can only call ten folks on your panel, which 10 should it be?’ And it might not be the people we have picked out.”

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