The vulnerable individuals in a health system’s patient population are at risk of becoming some of the organization’s most complex and costly members. Because vulnerability can be determined by long-term health status and social determinants of health (versus acute episodes), managing risk for these patients relies on a whole-person approach to care. Fee-for-service reimbursement hasn’t incentivized this comprehensive approach to care, but, under value-based payment models, health systems are increasingly rewarded for care that keeps patients well. The first challenge in addressing the needs of vulnerable patients is identifying those patients. Analytics-driven technologies can help health systems understand who is vulnerable in their populations and take actions to control risk for these patients.

1. Identifying Vulnerable Patients
and Why They Matter

2. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Identifying Social Determinants
As value-based payment models continue to
incentivize care for the whole patient (versus
acute, or episodic, care), health systems are
beginning to more effectively address the
most vulnerable patients in their populations.
By identifying the social determinants of
health, or variables that contribute to overall
wellbeing, health systems can focus on
vulnerable populations’ needs.
This will be an increasingly critical step in
population health management (PHM),
improving outcomes, and lowering costs.

3. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Addressing Vulnerable Patients Is Key to
Value-Based Contract Success
In healthcare, we often target care management
efforts on the most medically complex patients
(those with the most comorbidities).
A successful population health vision,
however, doesn’t focus solely on complex
care management, particularly as payment
shifts towards value-based models.

4. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Addressing Vulnerable Patients Is Key to
Value-Based Contract Success
The ongoing shift away from fee-for-service
reimbursement towards value-based care
incentivizes organizations to care for the whole
patient and understand all the factors (including
social determinants of health) contributing to an
individual’s health or wellness.
This requires understanding where a patient
lands on the continuum of wellness and what
contributes to that individual’s health or illness.

5. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Addressing Vulnerable Patients Is Key to
Value-Based Contract Success
Vulnerable patients, due to the determinants that
shape their health status, often need ongoing
community support.
For example, a patient without transportation to
a primary care provider (PCP) might miss follow-
up and preventive appointments without a care
manager to coordinate that access.
If the health system identifies this patient as
vulnerable, the care manager can connect
with community resources to arrange
assistance for the patient.

6. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
What Makes a Patient Vulnerable?
The first challenge in prioritizing care for
vulnerable patients is understanding who
those patients are.
Definitions of vulnerable patients differ
by use case and may further differ by
organization and location.
For example, if a natural disaster
impacts a population’s ability to access
care, the local health system may
consider that population vulnerable.

7. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
What Makes a Patient Vulnerable?
Populations that might seem clearly
vulnerable don’t always meet an
organization’s criteria for vulnerability.
For example, patients on Medicaid might
qualify by some definitions as vulnerable.
According to a Kaiser Family Foundation
study, however, if an organizations defines
vulnerability by access to care, Medicaid
patients may use health services too often
to qualify as vulnerable.

8. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
What Makes a Patient Vulnerable?
With little agreement across the healthcare
industry about which patients to include as
vulnerable, health systems must leverage
analytics-driven technology to identify the
social determinants that contribute to
vulnerability in their populations and the
barriers that may impact an individual’s
ability to maintain optimal health.

9. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Analytics-Driven Technology Helps Identify and
Engage the Most Vulnerable Patients
Tools, such as the Health Catalyst®
Population Builder, that leverage analytics to
understand a population, and interface easily
with other data sources, can help health
systems identify and define who’s vulnerable
in their populations.
These technologies allow health systems to
create and manage the definitions of the
population for intervention.

10. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Analytics-Driven Technology Helps Identify and
Engage the Most Vulnerable Patients
If a care manager needs to reach out to a
specific subpopulation of high-risk patients to
alert them to take particular action, she can use
the Population Builder to define the target
population, integrate that definition into workflow
tools to predict risk, and develop patient-
centered care plans for the identified population.
For example, a young adult male, age 21,
has a history of ED visits for anxiety.
He doesn’t have insurance or a PCP.

11. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Analytics-Driven Technology Helps Identify and
Engage the Most Vulnerable Patients
The young man goes to the ED when he is sick and
has had four visits within the last month for anxiety.
Using Population Builder, a health system can
identify patients who are vulnerable for ED
anxiety-related ED use, such as this patient,
based on variables including high ED use,
age group, lack of a PCP, and prescription
for antianxiety medication.
By identifying such vulnerable populations,
health systems can act, by recommending
behavioral health support, to reduce the
risk of ED visits.

12. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Improving Outcomes and Lowering Costs
Starts with the Most Vulnerable Patients
Aided by technology and analytics to identify
vulnerable patients and associated health
determinants, health systems can treat the
whole person, not just the diagnosis.
A healthcare organization must agree on
defining which variables and determinants
will identify groups who are the most
vulnerable in its specific population.

13. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
Improving Outcomes and Lowering Costs
Starts with the Most Vulnerable Patients
The organizations will include these factors as
they develop algorithms utilizing tools, such as
the Population Builder, to target the right rising-
risk patients for care management and long-term
community support.
Leveraging technology will help health systems
realize their PHM goals and achieve the IHI Triple
Aim of improving the patient experience, the
health of populations, and reducing per
capita costs of care.

14. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

15. © 2018 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
More about this topic
Link to original article for a more in-depth discussion.
Identifying Vulnerable Patients and Why They Matter
Care Management Analytics: Six Ways Data Drives Program Success
KimSu Marder, RN, CCM, Lead Care Manager
10 Motivational Interviewing Strategies for Deeper Patient Engagement in Care Management
KimSu Marder, RN, CCM, Lead Care Manager
Saving Lives: Effective Healthcare Communication Empowers Care Management
KimSu Marder, RN, CCM, Lead Care Manager
Ten Essential Steps for Your Readmission Reduction Program
KimSu Marder, RN, CCM, Lead Care Manager
Transitional Care Management: Five Steps to Fewer Readmissions, Improved Quality, and Lower Cost
KimSu Marder, RN, CCM, Lead Care Manager

16. © 2018 Health Catalyst
Proprietary. 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
Joined Health Catalyst in September 2015 as Care Manager Lead. Prior to coming to
Health Catalyst, she worked for Tufts Health Plan as Care Management Relationship
Manager. KimSu has a degree in Education from Lesley University, a degree in
Nursing from Regis College, and is currently working on a Psychiatric Nurse
Practitioner MSN at Regis College.
KimSu Marder