1. Determination of Highest Risk Patients Adult Patients

2. Objectives Describe the “highest risk” patients; the top 5%of patients most at risk for hospitalization, ER visits, and sentinel events. Describe the key components of the highest risk registry.

3. Why risk stratify? Identify patients with high problems – address priority needs. Maintain access to care. Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events. Utilize limited practice resources effectively. Decrease the utilization of resources downstream Decrease the overall cost of care – shift resources to PCP Other??

4. Identify Patients with Asthma in Panel Low Risk Asthma – Intermittent Medium Risk Mild Persistent Asthma High Risk Moderate or Severe Persistent asthma Pts in ER Pts Hospitalized Determine Priority Patient Need Medication Advanced Protocol Titration Upward Monitoring Advanced Self-care Asthma Education Adolescent GV Parent Support Class Monitoring calls ER Follow-up Call Social issues Transportation $$ for Meds Parental neglect Housing Patient F/U (PV) with Provider Determine Delivery Mechanisms Q 6 mos Phone F/U Care management Active Care Management Transition care Med Titration ? Home visit Asthma Clinic (Provider Present) Asthma Nurse Education Action Plan MS goal Group Visits (Provider Present) Parent Education Child Education Social Worker Advanced Medication Management Q X weeks Q X mo prn PRN Risk Stratification and Related Interventions Parent Asthma Management Class

5. Identify Patients with DM in Panel Low Risk Patients BP<130/80 A1c <7.0 LDL <100 Medium Risk Patients BP>130/80 <140/90 A1c >7.0< 8.0 LDL>100<130 High Risk Patients BP>140/90 A1c>9.0 LDL>130 Determine Priority Patient Need Medication Advanced Protocol Titration Upward Monitoring Advanced Self-care DM Education SM Support SM Class Monitoring Functional ability Social Support Transportation $$ for Visit, Meds, co-pays Abuse, etc. Determine Frequency of Patient F/U with Provider Determine Delivery Mode Lab q 3mo Q 6 MO Phone F/U Team management Monitoring (BG, SM Goal, BP) Phone follow-up Disease Clinic (with Provider) Titration BG Monitoring BP Monitoring DM Class DM Education SMS goal Group Visits ( with Provider) DM Education SMS goal Social Worker Q X mo PRN PRN as needed Risk Stratification and Related Interventions Lab q x mo Low risk Medium risk High risk Highest risk Highest Risk Patient BP>210/140 A1c>9.0 LDL>200 Pts in ER Pts Hospitalized Care management Close Monitoring (BG, SM Goal, BP, BMI, etc.) Titration of meds Scheduled phone follow-up All Risk per capacity) KEY

6. Risk Criteria  Degree of Disease Severity  BP  A1c  LDL  Utilization Frequency  Office Visits  Phone calls to the office  ER visits  Hospitalization

7. Risk Criteria  Self-care Deficit  Taking of meds  Following diet  Activity  Social Issues Phone  Transportation issues  Lack of support at home  Lack of resources $$$$$ 7

8. Risk and Interventions Differentiation Team and Medium and High Risk Patients – Group Visits – Group Education – Follow-up care with team CM and Highest Risk – Individual phone calls to adjust insulin and review symptoms – Specific patient action plan with hypoglycemic instructions 8

9. PCP/Medical Home Site Collaboration Direct referrals from PCP Review high risk list with PCP’s Medical Home support staff referrals

10. Predictive Molding Predictive analytics is the branch of data mining concerned with the prediction of future probabilities and trends.data mining An insurance company is likely to take into account potential driving safety predictors such as age, gender, and driving record when issuing car insurance policies. Multiple predictors are combined into a predictive model, which, when subjected to analysis, can be used to forecast future probabilities predictive model

11. Site# Forecasted Risk IndexAISCIS Risk RankSexAgeTotal Paid Forecasted CostPrimary ETG Group Program Status as of 8/27/08 1014.19135 5 M82$42,187.00$44,456.00 Cerebrovascular AccidentMHOpen 10148037 5 M68$46,972.00$43,405.00 Cardiovascular Surgery Closed-Need met 1016.2110028 5 M67$137,724.00$67,387.00Infectious DiseaseMHIdentified 1013.199325 5 F75$70,344.00$34,563.00 Degenerative Ortho disease MHCL- Needs meet 1014.539460 5 M81$49,157.00$49,173.00 Cerebrovascular Accident 10110.29751 5 F71$133,870.00$110,630.00 Renal Failure, Chronic & NephrosisMHOpen 1015.599062 5 M81$25,981.00$60,613.00 Renal Failure, Chronic & NephrosisMHIdentified 1028.879550 5 F79$113,895.00$96,235.00 Renal Failure, Chronic & NephrosisMHCL- CC Predictive Modeling

12. Process for Determining Highest Risk Patients All patients that are post discharge are at high risk for readmission. Review all list with PCP to identify which patients need intervention or fit criteria for Complex Case Management.

13. Questions? 13