- Identify specific individuals within your chosen population using multiple approaches.
- Develop real-time patient identification methods.
Below is guidance on how to begin using data to identify individuals and questions to discuss with primary care physicians who see patients in your population segment.
Tips and guidance for identifying patients who are a good fit for your program:
- Engaging clinicians and key stakeholders in the process of developing and applying identification strategies early and co-creating a referral process with providers are crucial to the success of the program.
- Use improvement methods to test self-reported health measures.
- Review examples of Identification criteria that organizations were testing in the IHI Better Health and Lower Costs for Patients with Complex Needs Collaborative .
Tips and guidance for real-time patient identification methods:
- Develop methods to identify potential patients at opportune times, such as during a hospitalization or ED visit, when their motivation to participate in enhanced programming maybe higher than usual.
- Co-locating care management staff of community health clinics, behavioral health clinics, and social service organizations in the hospital can be an effective way to identify potential patients, and is a practical and constructive way of collaborating across different organizations.
- Create coordinated, responsive, and easy communication methods between those who refer patients and care management staff.
- Partner with another organization that serves a high volume of your chosen population segment. Partnership methods around patient identification can be as simple as patient referral, or as sophisticated as developing a shared medical record to quickly identify individuals for the enhanced care program.
“The Camden Coalition has tiered the problem at two different levels. We have a model of care for the most extreme patients, the outliers, and then a model of care for the next tier down of hospitalized patients. We are focused on hospitalized patients or patients using the emergency room. Both tiers are data driven. Every morning we wake up with a list of folks from the Health Information Exchange, a regional list, so we know how often they’ve been back in the last couple of years and the last six months. Anyone with two or more admissions in six months, with medical and social and behavioral complexity, is eligible for the higher tier, high utilizer intervention, and anyone with one admission or emergency room use is eligible for the next tier down. We don’t take referrals from anyone so the entire intervention is data-driven, coming from these lists every morning. We have a full-time team up in the hospital, and every morning they wake up with the list and they go right to the bedside, enroll patients, and offer the opportunity to enroll. Our interventions right now are being studied, so this is a randomized control trial. The care managers consent the patient, walk out, randomize them, and then walk in and let them know if they’ve been enrolled. If they get enrolled, it’s a 90 to 100-day intervention, intense, wrap-around case management. It looks a lot like programs such as an ACT team or a PACE program.”Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers