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Risk stratified care management
 

Risk stratified care management

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    Risk stratified care management Risk stratified care management Document Transcript

    • Risk-Stratified Care Management and Coordination Table 1: Examples of Potentially Significant Risk Factors Clinical Diagnoses, Behavioral Health, Special Needs Potential Physical Limitations –  ny chronic disease, particularly one A that is not in control or at desired goal –  hronic pain C –  ubstance abuse S (alcohol/drug/tobacco) –  erminal illness T –  dvanced age with frailty A –  ultiple co-morbidities M –  re-term delivery of newborn P –  hild, youth, or adult with C special needs –  nxiety, schizophrenia, bipolar, depresA sion, or other behavior affecting health –  ental health D –  ementia/Alzheimer’s disease D Social Determinants Utilization/Claims Data – Non-ambulatory –  eeds Assistance with N Activities of Daily Living (ADLs) –  everely diminished S functional status –  eclining eyesight D –  xtreme weakness or fatigue E –  t risk for falls A –  ack of financial or family L support that impacts care – Unemployed –  o health insurance N –  ow health literacy L –  nsafe home environment U – Homeless –  ives alone and needs L assistance with ADLs –  ransportation for health care T appointments is difficult –  anguage barriers L –  requent hospitalizations F (particularly heart failure, GI disorders, and pneumonia) –  requent office, ER, or urgent F care visits –  ultiple providers M –  ospital readmission within H 30 days –  ajor procedure in last year M –  hronic kidney disease C –  rain trauma B –  xpensive medications E  Clinician Input (Personal Knowledge) –  olypharmacy – Patient is taking several medicaP tions that may not all be needed and/or could have potential for interactions –  igh-risk medications H –  on-compliant with treatment plan N –  onfusion with medications or following the treatC ment plan –  ecent move to long-term facility or other transition R of care –  pouse (who was the caregiver) recently deceased S –  ack of engagement in care plan L –  ow confidence or ability for L self-management –  nswer to the question: Is this patient at higher risk A for dying within the next year? Table 2: Risk Categories and Levels using Diabetes Example Case PRIMARY PREVENTION SECONDARY PREVENTION TERTIARY (Low Resource Use) (Moderate Resource Use) (High Resource Use) (Extremely High Resource Use) GOAL: To prevent onset of disease GOAL: To treat a disease and avoid serious complications GOAL: To treat the late or final stages of a disease and minimize disability GOAL: May range from restoring health to only providing comfort care Level 5 Level 6 CATEGORY Stage Level 1 Level 2 Level 3 Level 4 CATASTROPHIC/COMPLEX No known diagnoses or complex treatments Example of using uncontrolled progression of diabetes No known diagnoses but demonstrates warning signs or potentially significant risk factors Has diagnosis, but stabilized or in control; potentially significant risk factors Has diagnosis and/or complex treatment, and at higher risk for complications or potentially significant risk factors Has diagnosis, complex treatment, and complications or potentially significant risk factors– goal is to prevent further complications •  ery severe illness or condition and V potentially significant risk factors • End-of-life care • Premature baby (May have high costs with limited or no opportunity for improvement, stabilization, or cost control) • Healthy •  lood glucose and B lipids rising, but still within desired parameters •  iagnosed with type D 2 diabetes, blood sugar, and lipids brought within desired parameters •  lood sugar and B lipids not within desired parameters, and financial situation impacting negatively •  as diabetes with early renal H disease, coronary artery disease, failing eyesight, and lives alone • Diagnosed with lung cancer • BMI elevated •  arried, family M involved • Smoker •  hree ER visits and two T hospitalizations in past year ✓ Preventive screenings and  immunizations ✓ Patient education and engagement  ✓ Appropriate monitoring for warning signs  ✓ Health risk assessment (annual)  ✓ Care plan that includes smoking cessa tion counseling and program offered •  ual eligible D Medicaid/Medicare •  ne ER visit and O one hospitalization in past year Example of Care Plan Considerations for patient with uncontrolled progression of diabetes • Lives alone • Recent myocardial infarction •  rogression to ESRD with renal dialysis P • Amputation of one leg • Blind •  eeds Assistance with Activities of N Daily Living (ADLs) ✓ Preventive screenings and immunizations  ✓ Patient education and engagement  ✓ Appropriate monitoring  ✓  ealth risk assessment (semi-annual) H ✓  are plan with smoking cessation counseling C and program offered ✓ Team/planned care  ✓ Group visits  ✓ Health coach  ✓ Referrals as appropriate, such as social services  ✓ Community resources  ✓ Home self-monitoring  ✓  reventive screenings and P immunizations ✓  atient education and engagement P ✓ Appropriate monitoring ✓ Health risk assessment (quarterly)  ✓ Intensive care management plan  and resources ✓ Smoking cessation  ✓ Group visits ✓ Health coach ✓ Home health • Lives in nursing home ✓ Hospitalization  ✓ Rehabilitation  ✓ Long-term care  ✓ Hospice  ✓ Home health  ✓ ndividualized intensive care I management and coordination ✓ May or may not conduct preventive  screenings ✓ Health risk assessment, as appropriate  Identifying Disease Burden and Determining Health Risk Status Is the patient healthy, with no chronic disease, or significant risk factors? Is the patient healthy, but at risk for a chronic disease, or has other significant risk factors? Does the patient have one or more chronic diseases, with significant risk factors, but is stable or at desired treatment goals? Does the patient have one or more chronic diseases, with significant risk factors, and is unstable or not at treatment goal(s)? Does the patient have multiple chronic diseases, significant risk factors, complications, and/or complex treatment(s)? Does the patient have a catastrophic or complex condition in which his/her health may or may not be able to be restored? Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 PRIMARY PREVENTION PRIMARY PREVENTION SECONDARY PREVENTION SECONDARY PREVENTION TERTIARY PREVENTION CATASTROPHIC CARE GOAL: To prevent onset of disease (Low Resource Use) GOAL: To prevent onset of disease (Low Resource Use) GOAL: To treat a disease and avoid serious complications (Moderate Resource Use) GOAL: To treat a disease and avoid serious complications (Moderate Resource Use) GOAL: Treat the late or final stages of a disease and minimize disability (High Resource Use) GOAL: May range from restoring health to only providing comfort care (Extremely High Resource Use) CARE PLAN SUGGESTIONS CARE PLAN SUGGESTIONS CARE PLAN SUGGESTIONS CARE PLAN SUGGESTIONS CARE PLAN SUGGESTIONS CARE PLAN SUGGESTIONS –  reventive screenings P and immunizations –  atient education P –  ealth risk assessment H (annual) –  ppropriate monitoring A for warning signs –  reventive screenings P and immunizations –  atient education and P engagement –  ealth risk assessment H (annual) –  ppropriate monitoring A for warning signs – nterventions for unI healthy lifestyle/habits –  inks to community L resources to enhance patient education, selfmanagement skills, or special facilities –  reventive screenings P and immunizations –  atient education and P engagement –  ealth risk assessment H (semi-annual) –  ppropriate monitoring A for warning signs – nterventions for unI healthy lifestyle/habits –  inks to community L resources to enhance patient education, selfmanagement skills, or special facilities –  reventive screenings and P immunizations –  atient education and P engagement –  ealth risk assessment H (semi-annual) –  ppropriate monitoring for A warning signs – nterventions for unhealthy I lifestyle/habits –  inks to community resources L to enhance patient education, self-management skills, or special facilities –  reventive screenings and P immunizations –  atient education and engageP ment –  ealth risk assessment (quarterly) H –  ppropriate monitoring for A warning signs – nterventions for unhealthy I lifestyle/habits –  inks to community resources L to enhance patient education, self-management skills, or special facilities – Hospitalization – Rehabilitation –  ong-term care L –  ospice/palliative care H TEAM/PLANNED CARE TEAM/PLANNED CARE –  roup visits G –  ome self-monitoring H –  inks to the medical neighborL hood for care management, coordination of care, treatments, communication, and exchange of information with other providers and health care settings –  ealth coach H –  eferrals, as appropriate R –  roup visits G –  ome self-monitoring H – Links to the medical neighbor hood for coordination of care, treatments, communication, and exchange of information with other providers and health care settings –  ealth coach/personalized care H plan/management and resources –  eferrals, as appropriate R –  ome health H –  roup visits G –  ome self-monitoring H – Links to the medical  neighborhood for care management, coordination of care, treatments, communication, and exchange of information with other providers and health care settings TEAM/PLANNED CARE TEAM/PLANNED CARE –  upport groups S – Links to the medical neighborhood  for coordination of care, treatments, communication, and exchange of information with other providers and health care settings –  ealth coach/care management H –  eferrals, as appropriate R –  ome health H –  ersonalized intensive care plan/ P management and resources 11/12