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Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics
Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics
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Like the convenience of an instant PDF download but still want a hard copy of this book? Order both and save 35 percent!

Healthcare organizations employ a variety of tools and analytics to identify high-risk, high-cost patients for targeted population health interventions.

Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics presents a range of risk stratification practices to determine candidates for health coaching, case management, home visits, remote monitoring and other initiatives designed to engage individuals with chronic illness, improve health outcomes and reduce healthcare spend.

Each program discussion is supplemented by market data on risk stratification approaches for that care coordination intervention.

This 30-page report compiles risk stratification profiles for a range of programs from such industry leaders as Humana, Adventist Health, Taconic Professional Resources, Monarch Healthcare (a Pioneer ACO), Stanford Coordinated Care, Ochsner Health System and others.

Accompanying each risk stratification profile are HIN market metrics from 2013 and 2014 on the top methods for identifying candidates for these interventions, based on responses from hundreds of healthcare organizations: population health, health coaching, home visits, remote monitoring, case management and other programs that engage individuals, even the dually eligible, in efforts to avoid high cost patterns of healthcare utilization.

In the last twelve months, CMS has allocated millions of dollars to initiatives targeting “super-utilizers”—beneficiaries with complex, unaddressed health issues and a history of frequent encounters with healthcare providers.

Describing their organization's risk stratification methods in this report are the following subject matter experts:

  • Duals Risk Stratification:
    • Julie Faulhaber, vice president of Enterprise Medicaid for Health Care Services Corporation;
  • Case Management:
    • Jay Hale, LPC, CEAP, director of quality improvement and clinical operations at Carolina Behavioral Health Alliance (CBHA);
    • Annette Watson, senior vice president of community transformation for Taconic;
  • Population Health Management:
    • Colin LeClair, executive director of ACO for Monarch HealthCare;
    • Elizabeth Miller, RN, MSN, vice president of care management at White Memorial Medical Center, part of Adventist Health;
  • Remote Monitoring:
    • Gail Miller, vice president of telephonic clinical operations in Humana’s care management organization, Humana Cares/SeniorBridge;
  • Health Coaching:
    • Alicia Vail, RN, a health coach for Ochsner Health System; and
  • Home Visits:
    • Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care, a part of Stanford Hospital and Clinics.
    • Deborah Lyons, MSN, RN, NE-BC, network disease management executive director, Community Health Network, Indiana.

Table of Contents

  • Humana’s Predictive Algorithms Peg Candidates for Remote Monitoring
  • HIN Market Metric: Top Stratification Tools for Remote Monitoring
  • Taconic Connects High-Risk, High-Cost Patients to Case Management
  • HIN Market Metric: Top Stratification Tools for Case Management
  • CBHA Template for Telephonic Outreach to Behavioral Health Populations
  • HIN Market Metric: Top Stratification Tools for Telephonic Case Management
  • Monarch HealthCare Pioneer ACO Targets Cohort of High-Risk Patients
  • Adventist Health’s 7 Tools to Identify Groups for Population Health
  • HIN Market Metric: Top Stratification Tools for Population Health Management
  • Ochsner Health System Recruits Candidates for Health Coaching
  • HIN Market Metric: Top Stratification Tools for Health Coaching
  • Stanford Coordinated Care Prioritizes the High-Risk for Home Visits
  • Community Health Network Adapts LACE Tool for High-Risk Heart Failure Patients
  • HIN Market Metric: Top Stratification Tools for Home Visits
  • HCSC Outreach Locates Duals for Care and Service Planning
  • HIN Market Metric: Top Stratification Tools for Dual Eligibles Care Management
  • About the Contributors
Publication Date: August 2014
Number of Pages: 30
ISBN 10: 1-941329-34-9 (Print version); 1-941329-35-7 (PDF version)
ISBN 13: 978-1-941329-34-4 (Print version); 978-1-941329-35-1 (PDF version)
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