Care Transformation Center Blog

Three care management takeaways from #innovatecare14

Cabell Jonas

I recently attended the Care Innovation Summit, an event hosted by the Aspen Institute and the Advisory Board. The day was packed full of interesting speakers and compelling commentary.

Here are my care management-related takeaways from the day.

1. High-utilizers aren’t all the same—and shouldn’t get the same care management support

Jeffrey Brenner from the Camden Coalition knows quite a bit about high-risk patient care management, having spearheaded the ‘hotspotting’ approach. The group has been extraordinarily successful providing robust care management support to the riskiest and costliest percentage of the population that consumes the most resources.

Download Jeffrey's presentation on innovative approaches to caring for the very ill.

Having found that a one-size-fits-all care management intervention doesn’t work for all high-risk patients, the Camden Coalition is further sub-segmenting the high-risk group according to utilization risk drivers—an approach few providers are using effectively today.

It turns out that patients overutilizing the ED are a very different population than patients overutilizing the inpatient setting. ED overutilizers tend to be younger, with complex behavioral health issues, substance abuse problems, and less motivation to change behavior.

In contrast, inpatient over-utilizers are typically older, sicker, often times facing mortality, and more motivated to change behaviors. Brenner and the team at Camden Coalition have found that successfully reducing utilization means putting different care management interventions in place for these subpopulations.

The takeaway? Segmenting patients as high risk isn’t enough, and one high-risk care management intervention isn’t enough. Look closer at your high-risk populations and match the interventions to the drivers of utilization. This might mean adding non-clinical team members to interact with high-risk patients based in the community, or partnering to provide behavioral health resources to high-risk ED overutilizers.

2. The PCP shortage is an issue, but it's less pressing with team-based care

Estimates of PCP shortages always make headlines. But recently, so have solutions based on the use of non-physician staff and technology. Nearly everyone on the panel of the session, "How Innovative Employers Are Using Their Purchasing Power to Drive Value," agreed that more PCPs isn’t the only answer—especially since today’s challenges are patient engagement, activation, and self management.

One panelist put it best: "We've fixed things with a medical model, but we need to broaden our view—while tracking outcomes and metrics. Perhaps we don’t have a primary care shortage in our future if we just expand our view of what primary care means."

Virginia Mason has been using care teams to reduce costs for their employer partners, using NPs and PAs to extend the reach of the PCP, and pharmacists to manage specialized needs like medication management. Compass Care Engineering and Iora Health both use telemedicine approaches and 24/7 access to connect patients with RNs, non-clinical staff, or the PCP according to the specific need.

The takeaway? Providers must deploy interdisciplinary care teams. Having multi-leveled staff allows the team to be flexible to the patient need and pair the patient with the right health care professional at the right time, which will offer a chance to reduce employer health care costs and improve employee health.

3. The new "big data" is soft data on patient habits, preferences, lifestyle, and location

Clinical data helps shape a clinical protocol, but non-clinical data is equally critical to shaping a care management approach.

One organization managing risk noted, "Some of the richest data is on patient habits, preferences, lifestyle—‘soft’ issues that are difficult to analyze but are meaningful to care compliance."

"If you’ve never done a home visit on your high-risk patients, do one."

Cracking this data can seem daunting, but Camden Coalition’s original hotspotting effort came from one enthusiastic analyst, basic GIS, hospitalization data, and a spreadsheet. Additional ‘soft’ data came from conversations with EMS (“What addresses are you visiting the most?”) and visits to apartment buildings. A key suggestion for organizations interested in digging deeper into the non-clinical challenges in a patient’s life is to do a home visit.

Caregivers are also a rich source of information about compliance. Walgreens suggested that pharmacy-related data, such as failure to pick up a medication or a delayed pickup can offer insight into a patient lifestyle's regarding transportation or financial challenges.

The takeaway? Start collecting and analyzing soft data on high-utilizer patients to get a more holistic picture of the non-clinical and lifestyle realities that matter to their health.

How to Use Analytics to Segment Your Patient Population

Health Care Advisory Board members can join us for a webconference on June 12 to explore strategies for using both clinical and claims data to segment patients by risk level.


You might also like this blog post on two ways to match the right patient to the right intervention.

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More Highlights from the Summit

The Care Innovation Summit featured more than 60 thought leaders and hundreds of attendees. Get the scoop on what you missed.

What HHS and a hotspotter can teach us about health care innovation

Conway on innovation; Orszag vs. Scully 

Five panels tackle key challenges


How to Use Analytics to Segment Your Patient Population

Join us on June 12 for a webconference to explore strategies for using both clinical and claims data to segment patients by risk level. Save your spot »


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