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Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination
Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination
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Health risk stratification is scalable—whether grouping diabetics in a single practice without an EMR or drilling down to an ACO's subset of medication non-adherent diabetics with elevated HbA1cs who lack social supports.

That's the experience of Ochsner Health System, whose scaling and centralization of risk stratification and care coordination protocols across its nine-hospital system drive ROI and improve clinical outcomes and efficiency.

Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination explores Ochsner's approach, in which standardized scripts, tools and workflows are applied along the care continuum, from post-hospital and ER discharge telephonic follow-up to capture of complex cases for outpatient management.

In this 28-page report, Mark Green, system AVP of transition management at Ochsner Health System, presents four case studies demonstrating quality and financial gains accomplished by Ochsner's Care Coordination Center (C3) under Ochsner's Accountable Care program, which is charged with the system's clinical and non-clinical care coordination.

The case studies in Scalable Models in Health Risk Stratification: Results from Cross-Continuum Care Coordination document the benefits of Ochsner's shift from siloed approaches to consistent application of care coordination methodologies along the continuum.

This report provides details on the following:

  • Definitions of risk stratification and care coordination and potential for driving ROI from each;
  • Management of multiple patient groups, including the challenge of churning 'falling risk' patients along the risk continuum;
  • Leveraging of CMS's new transitional care management (TCM) codes to improve reimbursement and close gaps in care;
  • Ochsner's severity of illness (SOI) designation that supports the hospital system's resource and discharge management by acuity;
  • Metrics resulting from Ochsner's shift from siloed to automated approaches, including impact on hospital readmissions, regional management of hospital discharges, post-discharge follow-up, 48-hour call attempt rate, licensure integrity;
  • Maturation and future of health risk stratification and patient segmentation;
  • Opportunities for cross-continuum partnerships in healthcare models;

and much more.

Table of Contents

  • Moving the Metrics: Financial and Quality Returns from System-wide Care Coordination and Risk Stratification
    • Defining Risk Stratification and Care Coordination
    • Ochsner’s Risk Stratification Model
    • Practical Application of Risk Stratification
    • Case Study in Scalable Transitional Care Model
    • Results from Collaboration
    • Case Study: Improving Referrals with Severity of Illness Designations
    • Case Study: Moving from Siloed to Automated ED Discharge Follow-Up
    • Care Coordination and Risk Stratification: Collaborative Litmus Test
    • Future of Risk Segmentation
  • Q&A: Ask the Experts
    • Metrics to Determine ‘Falling Risk’ Patients
    • Partnerships with Non-Affiliated Hospitals
    • Impact of Automated ED Post-Discharge Follow-Up
    • Impact of Nurse Triage Line on Daytime and After-Hours ED Visits
    • Stratifying Newly Diagnosed CHF Patients
    • Disease-Specific Versus Holistic Care Management
  • Glossary
  • For More Information
  • About the Speaker
Publication Date: December 2014
Number of Pages: 28
ISBN 10: 1-941329-50-0 (Print version); 1-941329-51-9 (PDF version)
ISBN 13: 978-1-941329-50-4 (Print version); 978-1-941329-51-1 (PDF version)
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