Now that we have chosen our population segment, how will we find individual patients who are a good fit for our program?
Dr. Hong shares guidance on how to begin identifying individual patients. This process of identifying potential patients for enhanced programming is referred to as ‘patient identification’.
Why is this important? And what do we know?
- Enhanced care programs serving patients with complex needs and high costs carry a higher cost than usual care, with smaller caseloads and team-based care. If a program is going to survive financially, the enhanced care needs to be offered only to those people who are likely to benefit from it and whose health care costs are likely to be decreased through enhanced care. If a program were to engage people in care who are not a good fit for the care interventions, or for whom there is little opportunity to decrease costs, the team’s time, effort, and the cost of care would be wasted. To build a sustainable program that has the potential to serve the entire chosen population segment, it is important to determine the specific characteristics that indicate an individual is a good candidate to be a patient in enhanced care.
- Enhanced care program goals often include improved patient health and experience of care outcomes and a projected return on investment or cost-benefit analysis. Patient identification methods that are sensitive to patient characteristics that fit the program allow a team to position itself to meet its goals. Predicting the specific people who are likely to accrue high health care costs in the future is tricky. The challenge is that people who had high health care costs in the past may not correlate with those who will have high health care costs in the future.
- There is no magic bullet. All patient identification methods are imperfect: any one method will screen in people who are not the best fit for enhanced care; and will screen out, or miss, people who are a good fit. Given that, the best approach is to combine quantitative and qualitative identification methods, offering both redundancy and a wider net.
- The more time-sensitive your data is, the more rapidly your team can find potential patients. It is crucial to develop nimble real-time identification methods that allow your team to find and meet patients when they most need your service, and when their motivation to participate in enhanced programming is higher than usual. Real-time identification methods enable teams to meet potential patients as soon as knowledge of patient need is documented, streamlining access to care and aiding in patient engagement.
- Teams that are committed to quality improvement refine their identification methods as they serve more patients and learn more about their program, patient needs, and identification methods. This discipline around learning allows teams to develop the best possible identification methods.
How to get started identifying patients for your enhanced care
In the first step, “Choose your population and learn about its needs and assets,” you chose a population segment and defined its characteristics. You may have chosen, for example: patients with four or more chronic conditions; or patients with a combination of three or more hospitalizations in the past year and three or more emergency department visits; or patients experiencing homelessness; or patients over age 65 with frail health.
To get started on identifying people who fit the description of your chosen population, there are a few different things you can try:
Note that assessing the unique strengths and needs that each person presents with is part of engaging patients in care. For more on patient engagement, visit the Revolutionize Patient Engagement section.
Overall tips and guidance
- Commit to continually improve the work processes that the team uses to identify patients.
- Be aware that, over time, the characteristics of your chosen population segment might change – which means that you may need to revisit steps 1 (choose your population) and 2 (identify potential patients).
- Develop inclusion criteria – determine the characteristics or information that will screen potential patients into care.
- You may find it helpful to stratify the population segment with complex needs and high costs, meaning assessing relative levels of need or relative risk for high utilization in the future. This can be a way of prioritizing high-need subgroups for more immediate identification.
- Read further on how Denver Health and the Camden Coalition approach stratifying their population segment.
“What we’ve learned in our system is that the data is so out of date that it just frustrates our providers when you present them with high risk patients. They’re reviewing lists of which half aren’t their patients because we are still developing our empanelment process in primary care; a number of patients have died; others aren’t high risk at all; and other high risk patients are missing, making the lists not useful. It feels like a waste of time, which they do not have. So, we’ve moved, in our program, to strictly a provider referral approach. Eventually, we would like to go back to the quantitative identification approach. We are also doing chart reviews to find the folks who should be in the program but are not engaged by primary care. It’s intensive and time consuming, but can be more effective. We are taking our lists and saying, ‘Are there high-risk people that aren’t being seen in primary care that the provider might not know are high risk?’ It’s much more tedious, but we have had to do that because that is the state of our data for identification.” Clemens Hong, MD, a primary care physician, and Medical Director of Community Health and Improvement for Los Angeles County, California