Finding frail elderly key to managing them
Finding frail elderly key to managing them
Guidelines for developing assessment tools
Once you decide to engage in Medicare risk contracting, you have to make some important decisions about how to manage your Medicare population, particularly the high utilizers.
In order to manage the frail elderly, which is the population most likely to stay in the hospital for days on end and use the greatest amount of health care resources, you need to know how to identify them.
Health plans and provider groups across the country are learning how to assess seniors in order to find the frail elderly. Some use written questionnaires; others have assessment tools that are used over the telephone; still others research medical databases, looking for certain profiles.
Managed Care Strategies asked several provider and payer experts to discuss how they identify the frail elderly population in their areas. Here are some of their suggestions:
1. Define "at-risk elderly."
According to Mary Barrett Prybylo, RN, MSN, vice president of operations for National Care Management Partnership in Wallingford, CT, an at-risk senior can be defined as:
· a person with a chronic condition or illness;
· someone who is abused or neglected;
· a patient who is in need of caregiver support;
· someone who has multiple medications;
· a person who experiences transportation barriers;
· Someone who is illiterate, isolated, or impoverished;
· A patient who has more than three providers.
The Kaiser Permanente Center for Health Research in Portland, OR, includes in its frail elderly definition people who are dependent on others for daily care. The Center's assessment tool includes a frailty prediction model that selects 55% of the members whose health has declined or is expected to decline within the next 12 months, says Kathleen Brody, BS, PHN, the center's project administrator.
Saint Vincent Healthcare System of Worcester, MA, defines frail elderly patients as being anyone who is over age 85. "That' 5% of the elderly population, and that population accounts for more than 60% of all the costs that Medicare pays," says Christine C. Schuster, RN, MBA, vice president and chief operating officer of Saint Vincent's Extended Care Division.
2. Find the right tool.
"There are a lot of vendors who sell health risk assessment tools, so look for something that is simple, easy to comprehend, and can be mailed out," Prybylo says.
National Care Management Partnership is a subsidiary of Anthem Blue Cross and Blue Shield of Connecticut and of Connecticut Community Care, an independent case management company.
The Center for Health Research uses a questionnaire that is designed to be read by elderly people. It has a lot of white space, clear wording, and very few complicated questions, Brody says.
"You have to have a good cover letter that explains the way the data will be used so members feel confident about sharing this information," Brody says.
The Center for Health Research receives new survey participant files monthly from six Kaiser Permanente divisions. The data are loaded into a mail tracking system. Completed forms are scanned daily, and response data, including frailty prediction scores, are shipped weekly to the division, Brody says.
The Henry Ford Medical Group in Detroit uses a telephone survey that was developed by the Detroit-based Health Alliance Plan, says William A. Conway, MD, vice chairman of the medical group, which includes more than 1,000 physicians at 35 sites in the Detroit metropolitan area.
The Health Alliance Plan is an insurance company that covers 500,000 lives and has a Medicare risk contract with the Henry Ford Medical Group to cover 35,000 members.
3. Decide how to conduct the assessment.
Prybylo acknowledges that not all providers will be able to afford the time and money it takes to mail out assessment forms. Instead, they might hand forms to patients when they visit the provider, Prybylo says.
Providers also could conduct informal surveys with their patients, by asking clinical and support staff these questions:
· Who are our toughest patients?
· Who are the people who are the most challenging?
· Who are the people constantly in the office or constantly on the telephone because of a multitude of problems?
"This way they are relying on their staff to help identify frail elderly patients, and this isn't a bad way to start," Prybylo says.
Swedish American Hospital in Rockford, IL, informally assesses risk among its elderly population by having nursing and other clinical staff assess patients upon initial evaluation, says Henry Anderson, MD, FAAFP, vice president of professional services and chief quality officer of the Swedish American Health System, which includes 400 beds at the main hospital, nine outpatient clinics, private physician clinics, a home health agency, and an insurance company.
"The initial evaluation of these patients is critical because they start going down one pathway or another," Anderson says. "And when you're talking about the true elderly these days, it's the rare patient who doesn't have a multisystem disease."
Saint Vincent Healthcare System finds frail elderly patients through a variety of means, including asking physicians for information, looking at patient demographic data and researching pharmacy data to find patients who are taking certain medications that are indicators for chronic conditions, Schuster says.
For instance, most patients who have chronic obstructive pulmonary disease are prescribed a drug called Theodur, and most patients with congestive heart failure are on Lasix, Schuster says.
"So if you pull up a pharmacy log to see who is on Theodur and Lasix, you will see who might be at risk," she adds.
4. Track people who do not respond.
Prybylo says her company has an 80% return rate on its health risk appraisal form. The company achieves the high return rate partly because it follows up on people who did not respond or who did not answer all of the form's questions.
"There is a belief that those who don't respond might be your highest risk," Prybylo says. For example, a senior might be in the hospital and unable to respond to the survey, and this could be discovered when a surveyor calls the patient's home to find out why the form was not returned.
The Center for Health Research has achieved a 92% return rate in the Portland area by using a three-step mailing process, Brody says.
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