By Romanus Joseph, MBA, MSN, RN
Effective care management is critical for ACO success. That’s why we’ve developed the Smart Cohort tool: an actionable, rank–ordered patient outreach list that is generated from HealthVision, HDAI’s predictive analytics platform.
Designing a high value patient list for the whole Care Team
Care teams work together to coordinate a patient’s healthcare journey that tends to their physical, emotional, and social needs across providers and care settings using the HealthVision platform and informed by Smart Cohorts.
The Smart Cohort tool synthesizes the entire historical utilization, diagnosed conditions, and risk predictors from HealthVision to identify targeted, actionable, and impactable patients. The cohorts are “smart” because each one allows an ACO to match the list to its care team’s size and expertise.
Predictive models and strict criteria are used to segment patients into five categories.
- Low Risk (L)
- Rising Risk (R)
- Complex Care (C)
- Advanced Illness (A)
- Hospice Care (H)
Our partners use the Smart Cohort tool to:
- Identify patients who can benefit from palliative or hospice services.
- Enhance chronic disease management programs, such as CKD or Heart Failure.
- Reduce the number of patients who move to a higher risk group.
Now let’s take an example of a value-based care organization with 10,628 patients. The population health team uses HealthVision’s 90–day Predicted Risks to generate a stratified action list for the care team focused on the Advanced Illness Care (AIC) population, who are not currently in hospice. The list can be filtered down to the physician and patient level, giving teams a manageable group of targeted patients.
The Smart Cohort tool gives the care team the tools to act, preventing problems before they start. In addition to reducing care team burnout, the Smart Cohort tool can reduce ED visits, unplanned admissions, and increase appropriate referrals to palliative and hospice services.
Smart Cohort best practices:
For a deeper dive into how the Smart Cohort tool can help your care team become less reactive and more proactive, seeing greater impact from the same staffing levels, please contact us at [email protected].