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How ACO Claims Data Helped Save At-Risk Patients During the Pandemic

As the social distancing protocols crystallized early this spring — stay-at-home orders, fewer interactions with people and loved ones, and regular doctor’s visits flipped to telehealth or phone calls — Charleston Area Medical Center (CAMC) sensed an issue.

Leaders at the health system in Charleston, West Virginia, were concerned about certain segments of the population who normally interact with the system on a regular basis or could be at risk for a future inpatient admission or emergency department visit.

They wanted to proactively reach out to the at-risk groups with resources, comfort and care, but needed a means to risk-stratify so they could assess exactly which segments were in need of extra attention.

The population health team came up with a quick, reliable and effective solution: claims data.

During the COVID-19 crisis, many healthcare systems have discovered their population health infrastructure has been an invaluable resource to help identify and manage patients, which has resulted in improved patient experience, more timely access to appropriate care resources and better clinical outcomes. According to Premier’s recent survey, providers in alternative payment models (APMs) had a significant head start over other healthcare providers to manage the COVID-19 surge.

Medicare accountable care organizations (ACOs) receive claims data monthly regarding their beneficiaries’ utilization of services, and this data is often organized into claims analytics tools to help ACOs understand beneficiary utilization and cost patterns. This information allows the ACO to provide care management for patients with complex medical conditions, work more closely with post-acute providers, partner with community organizations around social determinant needs, and develop relevant and specific care protocols.

Given the focus on appropriate care and use of services, population health infrastructure becomes even more valuable when constraints are imposed on the system, like the current pandemic.

Use risk stratification and predictive analytics tools to segment high-risk beneficiaries.

Utilizing its claims analytics tool, the Medicare Shared Savings Program (MSSP) ACO at CAMC knew it had the technical expertise to begin identifying patients who would benefit from additional outreach during the COVID-19 pandemic.

For CAMC, the criteria included patients with a high probability of a future inpatient admission and ER visit, with a focus on patients discharged in the last three months. CAMC’s population health team further refined their list to patients with top chronic conditions, including chronic obstructive pulmonary disorder and congestive heart failure – conditions known to be vulnerable to adverse outcomes related to COVID-19.

Leading claims analytics tools offer specific functionality to identify high-risk beneficiaries through a defined stratification methodology. This capability allows care management teams to identify beneficiaries most likely to benefit from care coordination and subsequent intervention.

Using their claims analytics tool, providers should leverage a risk stratification methodology that identifies individuals for whom targeted outreach will be especially important. By way of example, a cancer patient on high-cost chemotherapy medication may not have alternative options to lower overall cost, but another patient with multiple frequent emergency department (ED) visits in the last six months will likely benefit from care management and coordination support.

Identify at-risk beneficiaries proactively.

APM participants were more than twice as likely than non-APM participants to utilize population health data systems to manage the surge. As providers seek to stabilize financial losses, they should continue relying on their population health data systems to identify patients at risk for severe adverse outcomes from a COVID-19 diagnosis, considering the following criteria:

  • 65 years and older, or disabled
  • High ED utilizer, defined as more than three ED visits in the past three months or more than six ED visits in the past six months
  • History of one or more of the following conditions: congestive heart failure, chronic obstructive pulmonary disease, asthma, other serious heart conditions, severe obesity (BMI >40), diabetes, chronic kidney disease undergoing dialysis, liver disease or any other condition causing the patient to be immunocompromised

As of late April, CAMC has called more than 600 patients within its ACO population. CAMC’s initial screening calls revealed patients with potential symptoms of COVID-19 or exacerbation of their chronic disease.

Connect risk stratification to existing care management screening processes.

Data-driven risk stratification represents the first step in leveraging population health infrastructure. Connecting data to providers in an actionable way via care management is the crucial next step. Eighty-one percent of APM participants were able to utilize their existing care management team to manage patients during the COVID-19 surge, compared to 51 percent of non-APM participants. CAMC’s care management staff worked with each patient’s physician to arrange for a telehealth visit or in-person visit, depending on their operations.

In addition, care management teams can integrate the list of patients into their existing workflow tools and processes. Beneficiaries with very-high or high-risk scores are assigned to clinical staff, while non-licensed staff support outreach efforts for moderate or low-risk beneficiaries. Accordingly, CAMC’s care management team made follow up calls to these patients to ensure the appointment was completed and the patient was improving.

During initial contact with patients, teams should consider screening for the following indicators:

  • Presence of a caregiver, available and capable of managing patient needs
  • Ability and understanding to stay home and avoid social gatherings
  • Access to supplies and medications to manage their condition(s)
  • Access to food and sundries
  • Access to safe housing, water and electricity (are they able to pay their rent/mortgage and utility bills during and beyond the crisis?)
  • Assess whether the patient has medical needs or questions to pass on to a nurse for a more in-depth medical assessment or telehealth visit

If a beneficiary has additional needs when screening is complete, a referral can be made to a nurse care manager, social worker and/or physician for further assessment and evaluation. A proactive screening approach and relevant referral model can also drive better utilization of telehealth visits for providers. Care management staff can coordinate with primary care providers to drive outreach efforts that ensure continuity of care and avoid duplication.

Many of the patients CAMC’s care management staff spoke with had problems obtaining prescriptions, so their team prepared a resource list of pharmacy delivery options to give to patients during calls. In addition, patients were overwhelmed with information about COVID-19, so the team provided education about how to take precautions, recognize warning signs and prevent spread of the disease.

CAMC believes its biggest win, however, is the positive response to the outreach calls to check in with the patients during the crisis with so much social isolation, especially in their rural areas.

As the COVID-19 pandemic continues, it is important to build a screening process that addresses the volume of beneficiaries who require proactive outreach. To that end, some organizations have enlisted available resources to provide initial outreach, including licensed, non-licensed and even displaced staff.

Risk stratification, care management capabilities and well-defined screening processes powerfully combine existing population health infrastructure to amplify access during an emergency or crisis.

This approach not only supports pandemic management efforts to keep beneficiaries safe and at home, but it also broadens the pool of beneficiaries likely appropriate for ongoing care management, given their current diagnoses.

While a second wave of COVID-19 cases is yet unknown, organizations should consider the suggestions here to prepare for subsequent outbreaks and emergencies in the months and years ahead. As organizations begin to ramp up for the post-pandemic “normal,” the care management team will be well-positioned to leverage synergy from COVID-19 outreach efforts to extend and expand on their value-based care outcomes.

Stepping into the post-pandemic stage, providers need to use existing population health resources to help vulnerable patients stay safe and reinforce self-care and provide appropriate precautions.

While ACOs await guidance regarding the near-term future for advanced payment models, now is the time connect at-risk populations with care resources in more timely, efficient and direct ways.

Population health management teams have used their analytic acumen and care coordination capabilities to support the delivery system during this unprecedented time. Premier’s ACO Intelligence Solution™ helps ACOs understand beneficiary utilization and cost patterns, which enables the ACO to provide care management for patients with complex medical conditions, work more closely with post-acute providers, partner with community organizations around social determinant needs and develop relevant and specific care protocols.

Contact us to learn more about how claims analytics tools enable better population health management and coordination across the health system.

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