Using Smart Data to Risk Stratify Your Communities
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Using Big Smart Data to Risk Stratify Your Communities Lisa Arvesen
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Transcript of Using Smart Data to Risk Stratify Your Communities
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
