Editor's note: This blog was updated on May 14, 2018.
Last year, your peers focused on improving care for high-risk patients, including optimizing care management caseloads and addressing acute behavioral health patient needs. But throughout the spring, many of your questions have shifted focus from the high- to rising-risk population, as well as to the collective impact of social determinants of health.
How to address the needs of your rising-risk patients
Here are your two most frequent questions—and the answers you need to know:
Every provider engaged in risk-based contracts agrees that effective care management for high-risk patients is a universal starting point. But to manage population health successfully, providers must invest in care management for "rising-risk" patients—each year, about 18% of such patients escalate into the high-risk category when not effectively managed. By investing in rising-risk patients' management, organizations can significantly slow the progression from the rising-risk to the high-risk patient cohort and avoid the associated costs.
To develop a sustainable strategy for identifying rising-risk patients and managing their care, keep in mind these key components:
Health systems are becoming more aware of the systemic effects of social determinants of health, as nonclinical risk factors are increasingly linked to adverse patient outcomes. To identify the most pressing social barriers to care, such as social isolation or food insecurity, start with these four steps:
Most programs strive for a positive financial ROI when they invest in addressing various social determinants of health, but—in the short-term—that's an often unattainable goal. In the interim, use process metrics as a proxy to estimate success during year one of a new initiative, then incorporate outcome measures in year two to fill the range of competencies outlined below.
After identifying these social and environmental risk factors, collaborate with community partners to build sustainable, community-centered programs. Here are three ways you can address nonclinical needs and improve outcomes through partnerships:
When hiring your population health team, why start from scratch when we've already vetted the best job descriptions from leading organizations?
Create your free account to access 2 resources each month, including the latest research and webinars.
You have 2 free members-only resources remaining this month remaining this month.
Never miss out on the latest innovative health care content tailored to you.