ACO Success Requires Precise Patient Population Definitions

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An ACO will fail without precise patient population definitions. ACOs need to define populations for many reasons, including identifying their members and attributing those patients to the correct …

An ACO will fail without precise patient population definitions. ACOs need to define populations for many reasons, including identifying their members and attributing those patients to the correct physician and performing population health analytics. The challenges to a good population definition are: multiple providers per member, multiple data sources, and multiple identifiers for each member. Using a clinical integration hierarchy to refine population and subpopulations will solve a lot of these issues. A data warehouse is the foundation that makes it possible.

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  • 1. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. © 2014 Health Catalyst www.healthcatalyst.com Proprietary. Feel free to share but we would appreciate a Health Catalyst citation. ACO Success Requires Precise Patient Population Definitions By Luke Skelley
  • 2. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. ACO Success Depends on Accurate Patient Population Definitions 2 Accountable Care Organizations (ACOs) must precisely pinpoint patient populations to understand the risk to customize solutions.
  • 3. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. How ACOs Use Population Definitions 3 ACOs define populations for four main reasons To identify their members and attribute those patients to the correct physician(s) To attribute the right patient to the right physician for pay-for-performance incentives To accurately report CMS and other quality measures To perform population health analytics that enable providers to effectively manage each patient’s health
  • 4. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Challenges to Defining an ACO Populations 4 ACOs identify high-risk members and manage their health more carefully by: • Performing analytics to predict likelihood of specific events • Tracking utilization trends across the full care continuum • Monitoring quality of care by facility and by provider.
  • 5. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Defining High Risk Populations 5 Key challenges in defining ACO populations. • Multiple providers per patient • Multiple data sources • Reconciling multiple identifiers for each member HOSPITALS REHABS PHARMACIES LABORATORIES SURGERY CENTERS DIALYSIS FACILITIES PRIVATE PRACTICE CLAIMS & BILLING NURSING HOMES HOME HEALTH
  • 6. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Clinical Integration Hierarchy 6 Health Catalyst recommends using a clinical hierarchy system for grouping these common clinical characteristics and identifying individuals who share these characteristics. Starting at the most-general and moving to the most-granular level, this hierarchy is as follows: 1: Clinical program: Twelve clinical programs make up a comprehensive healthcare delivery system. Primary Care Care Process Families e.g., Diabetes CV Care Process Families e.g., Heart Failure W&C Care Process Families e.g., Pregnancy G.I. Care Process Families e.g., LowerGI Disorders Resp- iratory Care Process Families e.g., Obstructive Lung Disorders Neuro Sciences Care Process Families e.g., Spine Disorders Musculo- skeletal Care Process Families e.g., Joint Replace- ment Surgery Care Process Families e.g., Urologic Disorders General Med Care Process Families e.g., Infectious Diseases Oncology Care Process Families e.g., Breast Cancer Peds Spec Care Process Families e.g., Peds CV Surg Mental Health Care Process Families e.g., Depression
  • 7. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Clinical Integration Hierarchy 7 2. Care process family: Each clinical program consists of multiple care process families. For Example: 3. Care process: Represents the most granular level of the hierarchy and may exist anywhere along the continuum of care. Cardiovascular clinical program Ischemic Heart Disease Vascular Disorders Heart Failure Heart Rhythm Disorders Ischemic Heart Disease care process family Hyperlipidemia Coronary Atherosclerosis Acute Myocardial Infarction Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Cardiac Rehab
  • 8. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Using Technology to Build and Refine Registries Health Catalyst has developed two main tools to easily, efficiently, and accurately define patient populations. These analytics applications run on top of our enterprise data warehouse platform. 8 Population Explorer Delivers a “starter set” of more than 1,000 different registries. It begins with standardized rules for creating the registry Then adds care mappings to bring additional data elements (like laboratory results) into the registry to create a more comprehensive rule for defining the population. Cohort Builder This analytics application enables more sophisticated definitions of a population. Teams of clinicians, analysts, and others work together using this tool to adjust and refine the population definition to suit the ACO’s specific needs. The level of refinement brought by these tools defines the ACO’s effectiveness and goes beyond the diagnosis codes to pick up those patients who might otherwise be missed.
  • 9. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Summary 9 Using EDW analysis tools mapped to a deep clinical integration hierarchy allows ACOs to develop the precise, detailed population definitions, and vastly improve quality and accuracy.
  • 10. © 2014 Health Catalyst www.healthcatalyst.comProprietary. Feel free to share but we would appreciate a Health Catalyst citation. Other Clinical Quality Improvement Resources Click to read additional information at www.healthcatalyst.com Luke Skelley joined Health Catalyst in May 2013. Luke’s clinical nursing background was in critical care and he managed organ and tissue donation programs for 13 years. His background includes orthopedic products, severity adjusted outcomes software for Medstat Group, clinical pathway development software for CareScience and prospective payment methodologies for Optum Insight. Luke was recruited by Navinet for a new line of clinical products for physician offices before they were acquired by Lumeris. Luke has a BSN and MSN in critical care nursing from the University of Tennessee and an MBA from Belmont University. How Would An Accountable Care Approach Change How A Patient is Treated? Also by Luke Skelley