EXECUTIVE SUMMARY

Risk-stratified care management can help bridge the distance between providing effective care and finding efficient ways to do so.

  • Think of risk in terms of what a patient needs, rather than as a cost.
  • Identify patients who need help managing their chronic conditions or navigating the healthcare system.
  • Shift to team-based approach is essential.

Risk-stratified care management is one way to provide effective and efficient care coordination/case management.

The philosophy behind relying on risk stratification is that not all patients with multiple comorbidities need the most complex care management resources. If improved data collection and risk stratification could identify precisely the patients who would benefit most, an organization can put its resources where they’re most needed and effective.

“When we first started talking about risk, everyone was using the word to mean the financial risk to the organization that a patient might incur,” says Bruce Bagley, MD, a family physician who works with Leavitt Partners on the accountable care learning collaborative project. Bagley formerly was medical director for quality improvement for the American Academy of Family Physicians (AAFP), and was the president and chief executive officer for TransforMED, a subsidiary of the AAFP, which helps primary care practices transform for success in value-based care.

“It was about the risk of an expensive payment,” Bagley says. “We turned the conversation around with a new vocabulary that says, ‘What is the risk that a patient needs extra help?’”

The goal is to identify individuals who need help managing their chronic conditions or navigating the fragmented care system and to provide that help in a timely way.

“If you do those two things, the money takes care of itself,” he explains.

For example, AAFP developed a chart that describes examples of potentially significant risk factors in the following five different categories:

  • clinical diagnoses, behavioral health, special needs;
  • potential physical limitations;
  • social determinants;
  • utilization;
  • clinician input (personal knowledge).

Each category has bullet point descriptions of conditions, ranging up to 11 bullet points. (The full chart is available at: http://bit.ly/2z5qius.)

“You can assign people to risk categories, determined by need,” Bagley says. “Then, you must have a strategy and resources for each category.”

The care plans are customized depending on a patient’s comorbidities and social determinants of health.

The conceptual framework consists of six levels, beginning with healthy people with no identified diagnoses or complex treatments, and progressing through the highest level of need in which the patient has a severe illness or condition, and risk factors that might include end-of-life care or high costs with limited opportunity for improvement, according to the AAFP chart.

Each level is accompanied by recommendations, including preventive screenings, immunizations, patient education, blood sugar monitoring, care manager visits, and hospice care.

Stratifying patients into one of the risk levels provides a framework to understand their health issues and needs, he says.

“People rely on billing data to come up with lists of the most expensive patients, and that’s their mindset,” Bagley says. “But it obviously misses a lot of people who should be on an intensive intervention list and who are about to become more expensive.”

Care management services need to address both those who need that level of attention now and patients who need more attention to prevent them from progressing to a higher level of risk.

“Only looking at the last two years of claims data is shortsighted,” Bagley says. “Clinicians might know that this person’s spouse just died, and now they’re socially isolated and can’t get around the house. Things like that don’t show up in claims data.”

Risk-stratified data also better inform care coordinators, helping them understand what strategic interventions might be useful. With this information, care managers can determine whether patients need Meals on Wheels, home care visits, or enlisting neighbors to check in on them every week or so, Bagley says.

“It’s hard to put this into computer algorithms. It has to be individualized,” he says.

Using risk stratification to drive care management is part of a new trend in the healthcare industry. It is based on the team approach to care, in which the physician, physician assistant, care managers and coordinators, and other healthcare professionals work collaboratively.

“For a long time, the doctor’s visit has been the central commodity in the business of healthcare,” Bagley says. “That is about to change as we move to value-based care and payment reform.”

Care coordinators are a key element of the new team approach. Much of what care coordinators do is organizational, providing patients the help they need and pulling in clinicians as needed, he says.

“This has to be a real team-based approach, where everybody is able to make decisions that are appropriate for their level of work,” Bagley says. “I think that team-based approach, at the heart of it, is a strategic distribution of the work.”

In a team-based approach, the care coordinator might call in a social worker, psychologist, or home care nurse, depending on patient need. “We need to get away from the hero model where the doctor is the source of all wisdom,” he says. “We need to enlist the skills of all care team members.”

This approach will require a change of philosophy for doctors, some of whom are not yet on board with case management, Bagley says.

But the team-based approach with care coordination/case management works better for patients because they receive what they need when they need it, he says.

“The team follows the individualized care plan. But once that care plan is laid out and there are problems, or things don’t work out, then the team goes back to the doctor,” Bagley explains. “This frees clinicians to spend more time with patients when their medical issues are not worked out yet.”

Routine activities, such as flu shots, foot exams for diabetic patients, and other monitoring actions, could be part of a systematic, high-reliability approach that does not require a doctor’s direct involvement, he says.

The role of risk stratification is to divide patients between those who need just an “attaboy” from those who need extra attention. “Those with multiple chronic illnesses that are not under control would need help from a professional who is trained and engaged to help them out,” Bagley says.

This approach also will work in the accountable care population health world in which case managers, primary care providers, and others focus on helping patients receive healthcare that is optimal for their conditions.