While we were talking, one executive quickly spoke up and said:
“You know I get the theory of why you'd want to target these patients. And we've built a model of care for them already. But, to be honest, we're just not seeing the returns we expect for this work. They're still using a LOT of emergency services.”
That wasn't the first time I'd heard this statement, and it wouldn't be the last.
Fast forward to 2018. Earlier in the year, our membership told us in detail that amidst continued capacity and budgetary pressures, they could no longer throw money at these under-performing high-risk models.
So, we undertook the research to find out why many high-risk programmes were not succeeding and what systems could do differently to see more of a return. We looked around the world at various high-risk models, and distilled what we heard into insights that spell both good and bad news for our members:
The good news
In terms of clinical services, most systems have all the right pieces. They've developed a single point of accountability (either a site or a clinician) and have even started to wrap in behavioural health services, medication management, and palliative care offerings.
This represents what most high-risk patients need from a clinical standpoint, and is thus a strong base to start with …
The bad news
… but clinical services alone are not going to get these patients in control of their condition or consistently managing their care. According to the Kaiser Family Foundation, clinical care has roughly a 10% impact on premature mortality. The other 90% of risk comes from genetics, social and environmental factors, and individual behaviour. In other words, non-clinical factors are often more important than clinical ones.
This is why most high-risk care models fail. We found that time and again, the models that consistently reduced unplanned utilisation were predicated on non-clinical services, and had the ultimate goal of transitioning patients to self-management. Unfortunately, programmes built this way were the exception, not the norm.
What we can do about it
Over the last few months, we've built a study that helps executives define what a successful high-risk patient programme looks like and provides insights into how to build—and scale—models with the resources we already have available.
This fall, we will bring this research to our members at two chief executive forums. First in London on 13 November, and then in Copenhagen on the 15th. Attendees will come away with an executive audit to ensure that the care models they're relying on have the right components and will in fact yield returns from these potentially powerful programmes.
To register for one of these meetings, please email us at gfhi@advisory.com.