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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.

Data and analytics will be central in ensuring we can look beyond the surface to create that value for patients and providers

One example of this includes the opportunity around readmissions not within 30 days, but rather at 60 and 90 days. In a world where 30-day readmissions are a focus because of payer scrutiny, we like many identified this as a top priority. As we explored the data, we found that 60- and 90- day readmissions were far more of an opportunity with rates much higher than 30-day readmissions. Different from the acute care focus of 30-day readmissions, 60- and 90-day readmissions implicate coordination opportunities in post-acute setting and ambulatory care. Not only were we focused on the wrong issue, but the work done to improve had limited value to the larger issue as well.

For outpatient care management, the analytics quickly gave us an indication that there was an opportunity for a higher level of effectiveness. As we examined the ‘high-cost’ population, we realized that patients in that category changed quickly and often; as quickly as the claims data was refreshed (monthly or quarterly) a new cohort of high-cost patients emerged. In literature, this phenomenon is termed regression to the mean and reflects the tendency of cost to spike briefly, but then returns to a baseline level of spend after an event. This was an insight that did not resonate until we were able to witness in our own data. The implication was that for care management, using this approach to identify patients eligible for the intervention meant that we were too late. Claims data is inherently delayed given that it reflects spend thathas already occurred compounded by the time needed to transfer from payer to provider. By the time a care manager had been dispatched to a patient, the event had occurred and the patient was back to baseline. For Advocate to realize a greater level of effectiveness, we would need to predict which patients were likely to incur a high-cost event and mitigate.

Once again, using our Hadoop data platform and leveraging more clinically focused as well as some historical claims information, we developed several different predictive models focused on events clinicians identified as preventable within 90 days by a telephonic care management intervention. The preventable events included hospital utilization (inpatient, observation, and emergency) for clinical care needs like an exacerbation of asthma or worsening of heart failure symptoms. Operationally, the goal was to flag these patients that were rising in risk of unnecessary utilization and for care managers to intervene quickly and resolve the risk. Analytically, the predictive models performed well-enough that we moved to pilot phase quickly with the heart failure model as a start.

Results so far have been extremely promising. The pilot has yielded no hospital utilization for patients intervened on and although early, a randomized trial is being planned. There have been additional learnings around how best to align analytic insight with operational realities including:

• Relying on the model alone for patient identification is not enough and an initial filter should be applied to gauge the patient’s eligibility for care management (such as, excluding SNF or hospice patients).

• The models are very targeted toward a specific disease and allow for an immediate focus on the disease even though patients may have multiple co-morbid conditions. This is a different approach than the traditional approach of a lengthy initial assessment.

• Related to the above, the predicted utilization was found to occur shortly after prediction and there is a need to act quickly to mitigate.

As we continue to learn in this new industry paradigm focused on value, the need for deeper insight is clear. Data and analytics will be central in ensuring we can look beyond the surface to create that value for patients and providers.