4 Ways to Pinpoint High-Risk, High-Cost Candidates for Case Management

4 Ways to Pinpoint High-Risk,
High-Cost Candidates for Case Management

Annette Watson on identifying high-risk patients for case managementProviders in a physician practice are a good starting point for case managers to identify high-risk or high-cost patients for case management, explains Annette Watson, RN-BC, CCM, MBA, senior VP of community transformation for Taconic Professional Resources (TPR).

The process of identifying high-risk, high-cost patients can be formal or informal. You can use internal sources; when TPR goes in, that is one of the baselines of understanding. We understand who the patients are and what the population is, because if they have not been using data or have not been in an Advanced Primary Care initiative, it is highly unlikely the practice will have a quantitative method in place when we arrive.

We begin by asking the practice providers who the sickest patients are. Second, we can use data available at the practice level, such as registries or reports that can be run from the EHR.

Third, we also look at the kind of data they get from external sources. For example, do they receive reports from payors that show some utilization activity? Many of those reports may be somewhat aged. They are not necessarily timely, which raises actionability questions. However, we found there are reports coming out from payors, particularly about recent ER use or hospital discharges, that are more timely, which allow the practices to look at data—still retrospectively in most cases but much more quickly than they were able to in the past.

And finally, hospital admission and discharge information is important. Depending on the model in a PCP, if a physician is not the admitting physician— that is, if the admission is from a specialist, hospitalist, or through the ER—it cannot be assumed the PCP has the admission and discharge information.

People may think physicians know about their patients being in the hospital, but that is not always the case.

In Advancing Primary Care with Embedded Case Management: Lessons from the Taconic IPA Pilot, a new report available from the Healthcare Intelligence Network, Ms. Watson describes Taconic's commitment to embedded case management.

In the 25-page resource, Ms. Watson, senior vice president of community transformation for Taconic, provides details on the following program concepts:

  • Assessing physician practice needs and readiness for an embedded case manager;
  • Framework of the Taconic embedded case management model;
  • The varied roles of embedded case managers in physician practices, from supporting CPC to meeting accountable care organization (ACO) and patient-centered medical home (PCMH) requirements;
  • Case management skill sets and domains, including patient empanelment and risk stratification;
  • Funding strategies for an embedded case manager program;
  • Patient referral sources and workflow strategies to maximize the embedded case manager function;
  • Using electronic medical records, patient registries, payor data and other tools within a practice to support the embedded case manager;
  • Taconic's trajectory from initial NCQA medical home recognition to the elevation of embedded case management to a separate enterprise;
and much more.

For more information or to order your copy today, click here now:

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A multi-user license will provide you with the right to install and use this information on your company's computer network for an unlimited number of additional workstations within your organization for a one-time fee. To have this valuable resource on your network, or to inquire about ordering bulk copies in print or Adobe PDF, please e-mail sales@hin.com or call 888-446-3530.

P.S. -- You may also be interested in these embedded case management resources: