Risk Assessment and Stratification

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Presentation transcript:

Risk Assessment and Stratification Identifying Highest Risk Patients and Developing Interventions for Them

Identify Your Sickest Patients Right now make a list of the 5-10 patients that worry you the most. name Are your lists the same as your co-workers? Why are these patients on your list? What can you (provider and care team) do to improve things for each of these patients? name

Systematically Do That What would happen if you made these lists every week or every two weeks? Who in your office would be responsible for following up with these patients? How would you carve out time for these staff to do this follow-up? How would you document the follow-up care?

How Might This Work Daily? What criteria would you use to classify a patient as high-risk during an office visit? How might you address the needs of patients you identify as high-risk during office visits? How can you find out which patients are in the hospital and are being discharged each day? How can you find out which patients have been in the ER in the past day or two?

Why Risk Stratify? Identify patients with highest needs – prioritize. Utilize limited practice resources effectively. Use to determine visit frequency. Maintain access to care. Biggest bang for the buck is to focus on high risk! Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events. Decrease the utilization of resources downstream. Decrease the overall cost of care. Shift resources to PCP.

Risk Factors to Consider Degree of Disease Severity Pick a number for BP, A1C, LDL, etc. Utilization Frequency Office Visits Phone calls to the office ER visits Hospitalization Self-care Deficit Taking of meds Following diet Activity Social Issues Phone Transportation issues Lack of support at home Lack of resources $$$$$

Looking at Your Highest Risk A1C >9? LDL >130? BP >160/95? Calculate how many you have? Maybe you need to start even higher Looking for the worst 5-10%

Looking at Your Highest Risk Have they been seen in last 6 months? Bring them in! What can be done different? Self-Management Support! Depression?

Step-wise Approach to Risk and Intervention Stratification Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention STEP 3 Getting Medium and High Patients in for Follow-up Visits Step-wise Approach to Risk and Intervention Stratification STEP 2 Giving DM Planned Care at Every Visit STE P 1 Building Registry Functionality for Patients with DM

Questions? The second change concept is about how we work together.