Health care organizations unveil innovations unlocking greater value in enhanced care coordination, collaboration and evidence-based medicine
“Care coordination takes on meaningful value once you know which patients can readily benefit from a targeted care program.” -- Alejandro Reti, M.D., Optum’s chief medical officer for Analytics
As health care organizations continue to create value-based care initiatives, being able to accurately identify patients who will benefit most from targeted care interventions is critical. But, with more patients moving into population health programs and an ever-expanding information pipeline, how do you know if you are targeting the right patients for such interventions? “It’s all about choosing the appropriate focus,” says Alejandro Reti, M.D., Optum’s chief medical officer for Analytics.
Breaking Through the Data: Whose Care Are You Coordinating?
Reti proposes that organizations need to view value-based care through a new lens for it to have the biggest clinical and financial impact. “Care coordination doesn't resolve all health care challenges. You need to know which patients can readily benefit from a targeted care program,” says Reti. “All barriers to health are not equal.” Reti notes that Optum is working with care providers to understand the concept of impressionable risk to better characterize the differences between patients who respond to programs and those who don’t.
“A program’s effectiveness relies on the strategic selection of risk analytics,” says Reti. For example, hospitals often design programs focused on reducing avoidable hospitalizations but make the mistake of relying solely on a total cost predictive model to direct patients to that program. While it’s true that there is a strong relationship between total costs and hospitalization rates, Reti believes there are better ways of using analytics to identify patients who are at risk of being hospitalized, such as focusing on those who have conditions that can be treated in an outpatient setting. “Models that look at risk of hospitalization or even risk of avoidable hospitalization are a better choice,” he says.
Using analytics, health care organizations can uncover recent hospitalizations, complex chronic diseases, and signs of poor disease control or therapy adherence to find patients who need help. Analytics can also be used to identify patients who require costly care, such as those undergoing active cancer treatments or in a terminal stage of an illness. “One of the things we are doing right now is looking at behavioral health and other factors to better identify patients likely to be responsive, so we can help advise hospitals on which types of programs better fit which patients,” says Reti.
At the same time, Reti points out recent studies on value-based care initiatives, particularly those aimed at reducing inpatient utilization and reducing total costs, have shown mixed results over the last few years. “One reason for this is hospitals are diluting what is already too little activity across too many patients,” says Reti. “If 10 percent of your total attributed population is qualifying for the high-risk program, and you are trying to reach them all, that is too many.”
Redefining Care Spectrum Strategies
Meanwhile, care providers are developing new approaches to meeting the full spectrum of patient care needs, including medical treatment, prescriptions and care plan adherence – with a spotlight on primary care. “Engaging the primary care provider in the process is incredibly important,” says Reti. “More organizations we work with are taking steps to do things as simple as identifying overlooked gaps in care at every specialist and primary care visit.” These data help them be more vigilant about addressing evidence-based quality measures, such as controlled blood pressure or blood sugar, and focus responsibility for action onto each clinician involved in a patient’s care.
“One medical group we work with has been particularly successful at focused information sharing,” says Reti. When the group began sharing information about patients with diabetes who had poor blood sugar control, they discovered that high-performing physicians tended to be more willing to make adjustments to their pharmaceutical regimens. They were also more likely to bring patients in for a visit every three months instead of every six, he notes.
Having a plan that addresses prescription drug adherence is another key component of care. This requires stronger collaboration among pharmacists, physicians and other care providers, as well as a sharp focus on data and analytics to ensure information is shared and that prescribing patterns fit into the patient’s overall care plan. “At Optum, research tells us that medication adherence is associated with fewer avoidable admissions,” says Reti. “The right predictive model can prospectively identify patients likely to have adherence issues.”
Finally, it’s critical to look at behavioral health and nonmedical support. Care providers need better behavioral health data, such as routinely collected depression scores, says Reti. He points out that pairing behavioral health specialists with clinical health specialists has been effective in addressing conditions such as depression and anxiety. “The evidence overwhelmingly supports the complicating effects of depression on chronic disease management,” says Reti. “Addressing the social sphere is also necessary to make a difference with some of the most challenged and often highest-cost patients,” he adds. For example, Florida Hospital in Orlando has been a pioneer in addressing homelessness as a path to reducing uncompensated care. By the time the hospital had spent $1.6 million of a pledged $6 million for supportive housing, they had already seen a $2.5 million reduction in uncompensated care.1
With a sharp focus on identifying the right patients for interventions, a comprehensive approach to patient care and purposeful collaboration among care providers, health care organizations are well-equipped to support positive clinical outcomes. “You need to be prepared to go where the trouble is and be prepared to make a difference,” says Reti.
Sources:
1. http://www.trusteemag.com/articles/1182-housing-programs-lay-foundation-for-health
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