Manage High-Risk Members and Transitions-Of-Care

Managing High-Risk Members and Transitions

A small portion of your plan's membership may drive a large portion of your spend. Patient intervention requires the identification of members that are likely to incur high costs, so they can be enrolled in care management and transitions-of-care programs to improve their health and risk. The first step is to explore claims data, stratify members by risk, and identify the individuals who would generate the highest return on investment from an outreach program. Payers may want to go beyond identifying members who have been hospitalized to also include those with potentially costly risk factors who have not yet landed in the ER.

Stratifying members based on risk factors can help you identify those for whom clinical care intervention can provide strong benefits and savings before they rack up costly charges. Population health management solutions can also help you uncover other costly healthcare patterns, such as members seeking primary care in high-cost settings or physicians prescribing expensive drugs despite the availability of less expensive alternatives.

Care Management to Lower Risk

Care management programs can help to improve healthcare quality indicators and lower costs for populations with multiple chronic conditions by facilitating health choices and identifying barriers that could be removed. They can also help close gaps-in-care for members with chronic diseases. Population health management technology can provide care managers with ongoing visibility into the health of the targeted members, allowing care managers to talk with members about their health in a broader way than with access to EHRs alone.

Care managers members identified for outreach by predictive risk stratification analytics. A care manager conducts a comprehensive assessment interview to understand each of the identified members needs and then provides education and support, emphasizing self-management skills and follow-through with the patient's medical care plan.

Transition-of-Care Programs to Lower Risk

Hospital discharge is good opportunity for intervention by a care manager. Transition-of-care programs for hospitalized members with high risk scores may reduce potentially preventable readmissions by engaging high-risk members upon discharge.

Care managers can use comprehensive data about the patient aggregated from multiple sources to manage the care of members who are enrolled in a transitions-of-care program, ensuring the members understand their post-discharge plans and follow-up instructions and to identify and remove barriers to success.

Studiomaca Technology for Risk Intervention

Care management and transitions-of-care programs may reduce admits, days of hospitalization, readmits and ER visits. Learn how Studiomaca Risk Manager™ can stratify populations to identify individuals who pose the highest risk to the plan and support care managers by aggregating patient data in one place for more effective interactions with these high-risk members.

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