Partnering to Lead: FQHCs Drive Quality Patient Care with a

Clinically Integrated Network

Steps to Build a Risk-Stratified Care Management Program

Amanda Simmons, Executive Vice President at Integrated Health Partners of Southern California 
Hope Kraatz, Assistant Clinical Director at Integrated Health Partners of Southern California 

So now let’s talk about steps on how you build a program. We’ve kind of organized this into five sections of work, but I wanted you to note that the provider is at the top of the continuum. We believe that care is done best when it’s done at the PCP level and developing care management strategies that are led by physicians are really the best in the most successful in my experience. Starting off, we wanna look at patient selection, and this is where we identify all the patients that are attributed to your health plan, regardless if they’ve been seen or not, or not. This kind of changes our lens from the patients that are just in our, that just come in for a visit to looking at their entire population. Many times you get this information from health plan eligibility, but there are other forms to receive as well. This is the time that we’re gonna start to stratify your population to understand where all of the patients should be segmented into and who we should focus on first. Another strategy at this step is really to start focusing on the empanelment of your practices and just evenly distributing the pa patient populations to your providers. This is also an opportunity to start shifting to time to visits, how many visits, and looking at strategies to, for outcomes and, and population management tools.

Once we have identified our patients and we’ve stratified them, we can move into the enrollment step of care management. And this is the patient engagement step, and probably the most important. Obviously, if our patients aren’t engaged, we don’t have a lot of effectiveness in deploying very many strategies. So developing methods that we can ensure that patient engagement is secure. Number one is making sure that we have the right phone numbers, right contact information, et cetera. Health plans are really also a good help in helping us discern that information. You know, annual wellness visits are also a really key time to make sure and verify that patient contact information is accurate. The other thing is, is really this is where we talk about physician-led, is having our physicians start driving the conversation and introducing them into those, those care management programs, regardless of what they are, each patient will have, based on their risk, will have a different level of enrollment necessary needed to be participating in care management. For example, for our low-risk patients, enrollment is not necessarily a phone call or a physician handoff. Enrollment may be a text reminding them that their annual wellness visit is due or that their breast cancer screening is dual. Enrollment for maybe a high-risk patient will look different in the sense that those are complex advanced disease type patients, and that may require more of a physician handoff, team huddles, and more collaborative care opportunities that we would see with that segment of patients.

The third step that we outlined is case management. Now, within our populations, not all patients need case management, but it is an important piece, step in the management of the risk of your populations within the high-risk. And high highly risk complex cases. Case management probably is one of the best interventions to the one-on-one intent services, but case management doesn’t always have to be that way necessarily maybe for the low-risk, it’s more of just a coordinated effort or a warm touch at their annual wellness visit. The fourth step in risk strategy building a risk-stratified care management program is coordination. Again, depending on the risk level there, this intensity of intervention is different For low risk, it’s, it may be just coordinating their annual wellness visit and keeping them engaged with your health system for more of the high-risk patients that may be doing more of the referral management pieces, ensuring that the patients get to the right network, ensuring that information flows back to providers, ensuring that care is coordinated between all the specialties and that patients aren’t lost in the system.

The fourth step in a care management program is graduation. It’s probably the most important step, and I, a step that I see gets a, lead or eliminated most often and a graduation step is really that evaluation piece. As we talked about, patients don’t always stay in the same risk segment that we’ve initially identified. So developing strategies to move them into the appropriate risk category as well as to graduate them out of their program. In my experience, case managers like to hang onto their patients for years and years and years. It’s a relationship that they have with them. It’s important, but make sure that the interventions and strategies and the risk that we have identified is appropriate for services.

Evaluate Practice Performance Metrics for eConsult Programs - Measuring Access to Specialty Care

Evaluate Practice Performance Metrics for eConsult Programs:

Measuring Patient Access to Specialty Care

With considerable time and effort, at-risk practices identify patients at high risk of serious health events. We want to use this same information to develop an eConsult strategy.

To increase patient access to specialty care, consider which specialties have long appointment wait times, higher costs, conditions easily manage by the PCP, or do not require a face-to-face specialist visit. Using eConsults in these situations will drive cost savings, improve outcomes and decrease the risk of:

  • ED use – a costly alternative to a specialist visit.
  • Unscheduled or canceled specialty care appointments.
  • Boomerang appointments to primary care.

Increasing access to specialty care is the goal. Together, we can track and communicate which specialties are most:

  • Needed by the patients you serve
  • Likely to improve outcomes
  • Appropriate for eConsult
  • Valuable to your practice

Identify Specialties with Long Appointment Wait Times

There are many reasons why patients must wait too long to get an appointment with a specialist.

  • Not all specialists accept Medicare and Medicaid.
  • Doctors in many specialty areas are unevenly distributed across the country.
  • Patient referrals are often scheduled by the urgency of the condition.
  • Current patients are prioritized for appointments.

Merritt Hawkins reports that the nationwide average wait time to see an orthopedic surgeon is relatively short – just 16.9 days. However, looking at the average can be misleading.

  • This average is a 48% increase when compared to 2017
  • Getting an appointment with an orthopedist varies tremendously by location – San Diego averages 55 days!

Several factors impact appointment wait times. Not all specialists accept Medicare and Medicaid. Specialists are often clustered in metropolitan areas and unevenly distributed across the county.

Patient’s are less likely to schedule and attend a specialist appointment:

  • When the wait time is extended.
  • Travel distance to the specialist is significant.
  • Cost of the appointment is high — the patient has high-deductible insurance, or the specialist is out-of-network.

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