Using Big Smart Data to RiskStratify Your Communities

Lisa Arvesen

Risk Insight

Outcomes

Referrals Readmissions

Performance

Population Health Management

Health

outcomes

of a group

of

individuals

A provider’s patient panel

How do we take care of

this population of patients?

Risk stratification tools that are

based on historical data targeting patients that

presented with high utilization

Aggregation of patient

data across multiple

health information

technology resources,

the analysis of that data

into a single, actionable

patient record, and the

actions through which

care providers can

improve both clinical

and financial outcomes.

Broad based

approach by

managing the

health and

cost of care of

a population

Effective Population Health Management

Timely information

Reducing fragmentation of services

Improving coordination of care

Increasing access to care

Engaging the patient

“When we want your opinion, we’ll give it to you.”

“Tell me your thoughts.”

Improve the individual

experience of care

Improve the health of

populations

Reduce per capita costs of care for

populations

Improve Health

Better Care

TRIPPLE AIM

Lower Costs

ASSESS STRATIFYPopulation Identification Health Assessment Risk Stratification Enrollment / Engagement Strategies Management / Interventions

1DEFINE

2 3 4ENGAGE

5MANAGE

Tailored Interventions—

Care Coordination—

Disease / Case Management—

Health Risk Management—

Health Promotion / Wellness

Shared Medical Appointments

What Is A Shared Medical Appointment (SMA)?

The Doctor Will See You All…Together• Improve access to care (decrease waiting time)• Improve efficiency • Integrate health services – ‘wrap the services around the

patient’• Improve patient and provider satisfaction• Improve health outcomes

The Doctor Will See You and You and You…

What Patients Think about SMAs• Knowing they are not alone• More time with provider• Shared problem forum• Learned from the experiences of others• Peer pressure – good to share and compare• Meet new people• Motivational• Support out of the visit among patients

Population Health Management In Action

This is Donald

Hospital Analysis of COPD Patients

• Median HH Income is $55,168• Average age is 58• Family Households is 92.6%• Psychographic Profile

• Life Mode• Top Tapestry

Profiles

Campaign Is

Launched

How Do You Feel Donald?

Donald responds, “I am having difficulty breathing.”

PCP Pulmonologist

Donald Is Well Again

Thank You!Lisa.Arvesen@YourCareUniverse.com

Follow @YourCareU