Population Health for many in the industry has ushered in a plethora of new approaches on how best to manage the health and well-being of patients. Although not ‘new’ for existing risk models like HMO, for providers long successful in fee for service, this has been a cataclysmic shift in strategy and corresponding needs around infrastructure, resources, technology, and data. The changes reflect a focus on providing the best care outside of unnecessary and expensive venues and ensuring the best quality of care by better understanding patient needs beyond acute care.
Many of the investments are immediate for organizations that have historically focused on episodes of care singularly and include infrastructure to create a more complete continuum of care as well as new functions that help create tighter transitions across that continuum such as outpatient care management. Outpatient care managers have become central in supporting a level of triage and navigation for patients needing to interface with a large health system; appropriately resourcing patients to ensure the best possible health outcomes. For any organization deploying outpatient care management as an intervention, the question quickly becomes—which patients are assigned an outpatient care manager? With 3 percent of patients accounting for 40-50 percent of total spend, the answer is obvious—as many of the 3 percent as possible.
For Advocate Health Care, a large integrated healthcare system based in the Chicago land area with close to 1,000,000 attributed lives across a variety of full risk and shared savings contracts, a significant initial focus was the creation of a robust outpatient care management infrastructure. Approximately 80 outpatient care managers help navigate and triage patient needs via telephonic outreach to patients. Patients initially targeted, were identified through claim data streams as being highest cost in care.
As any newly formed ACO, the learning curve was steep, but incrementally with the other infrastructure needs; we continued to build out a data platform in Hadoop that integrated multiple EMR sources with 30+ different claims stream sources. Ensuring we can understand all care provided to patients across the continuum and create a patient-centered data platform was a departure from the episodic focus in a fee-for-service world.