Engaging High Risk Patients through Care Management (Part 1)


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

One of the most challenging issues in healthcare today involves “patient engagement”. It is defined by the Center for Advancing Health as “Actions individuals must take to obtain the greatest benefit from the health care services available to them”. The importance of patient engagement is undeniable. Patients active in the participation of their own care have a greater likelihood of achieving successful outcomes. How providers should approach patient engagement for different patient segments is still an evolving science. Patient engagement requires different levels of care management relationships and tools for different segments. In this two-part blog post, I am going to focus on the highest risk segment, and will address lower risk segments at another time.

Population health management is a large undertaking, requiring a variety of approaches to assure broad impact. The figure below shows an example of patient segmentation along with the types of care management relationships and tools appropriate for each segment. At the top of the pyramid is the highest 5 percent in terms of risk. In the middle are the 30 percent of patients with rising risk. The base of the pyramid is the 65 percent identified as having low risk. Let’s examine the segments more closely to see how patient engagement and care management strategies can vary between the segments.

CM Pyramid

 

High Risk

The top 5 percent of patients require high-intensity, 1 to 1 care management involving a multi-disciplinary team. Patients may have comorbidities that require more complex coordination across the continuum of care. Due to the high clinical risk for this group of patients, a care manager needs to play a lead role within the care team, guiding patients to take the actions needed to obtain the greatest benefit from the health care services available to them. Therefore, a patient engagement strategy for high-risk patients is really centered on high-intensity care management providing direction to the appropriate level of care and education about symptom monitoring and action plans.

Rising Risk

In general, the rising risk segment requires moderate intensity care management services, referred to as condition management in the diagram. These patients can pose an escalation risk if unmanaged, so the emphasis is on providing a consistent set of evidence-based care or education about self-management of a newly diagnosed condition. Patient engagement for medium risk patients is often a combination of consistent patient outreach and communication along with tools to encourage self-management. Within this group, there can be a subset of patients identified as “movers”, patients whose level of clinical risk is predicted to increase over the next 12 months. Higher intensity care management can be appropriate for “movers” in order to proactively address their conditions before they become more acute.

Low Risk

The low risk segment is the largest group, nearly two-thirds of the population. The focus for this segment is on preventive health and wellness to provide age and gender appropriate recommendations for care. Wellness tools including patient education and coaching may center around lifestyle choices and illness prevention based on health risk assessment data. Due to the size of this segment, low-risk patients must take on more of the responsibility for self-care. They are the ideal segment to benefit from patient engagement and outreach tools such as an interactive portal and patient reminders.

In the second part of this post that will be published next week, I will go deeper into technology designed to achieve effective high-intensity care management.