Milestone 2: Risk Stratifying Populations
Establish process to review and use Empire reports and MMH+ for population health management and high-risk patient stratification
Part of patient-centered care is using your practice’s resources in a way that can have the greatest positive impact. It’s difficult to know where to focus your time and attention without some population health analysis.
Stratifying populations is a way to identify the patients who can most benefit from additional guidance and attention from the practice care team, then identify the interventions that will do the most good.
A risk stratification score can be a simple list of any combination of the following variables, including but not limited to: patient demographics; utilization; diagnoses; prescription fill information; co-morbidities and historic costs.
We provide participating practices tools and resources to get started with risk stratification and population health management. This section of the Provider Toolkit includes inputs from an academic and best practice perspective, as well as a systems approach. The information in this toolkit is meant to help participating practices build a foundation for risk stratification methodologies, then expand and refine methodologies as practice capabilities grow.
This self-guided presentation introduces Member Medical History Plus, or MMH+, our longitudinal patient record. In addition to basic logon information, this presentation shows the kinds of information available via MMH+, and includes hypothetical scenarios that demonstrate how using MMH+ can help improve patient care.
Illustrated reference guide for using basic MMH+ system features and functions.
A quick reference handout for registering on Availity® and accessing Patient Centered Care reports.
Availity registration is your key to accessing reports you’ll be using in the patient-centered primary care program. This step-by step training deck details the registration process via the www.availity.com
site and simple, how-to’s for the user.
Empire Report User Guides:
This user guide shares details of the Attribution Active report which identifies the patient population for whom the provider is responsible.
This user guide shares details of the Attribution Inactive report which identifies the patient population who are no longer attributed to the provider.
This User Guide shares details of the Care Opportunity Report which is designed to identify the attributed members with “care opportunities.” Care Opportunities are situations where there are active or potential gaps in care associated with recommended evidenced based care and our clinical quality metrics.
This user guide shares details of the Emergency Room report which identifies the patient population for whom the provider is responsible.
This user guide shares details of the Hot Spotter Report which is designed to give providers and care team members a “heads up” when their attributed patients appear to be at risk for inpatient readmissions, or could benefit from an intervention by the primary care team.
This user guide shares details of the Inpatient Authorization report which identifies the patient population for whom the provider is responsible.
As you are using your new reports to support patient outreach and care planning, this robust glossary will help you increase your familiarity with report terminology and abbreviations.
A guide to care management for patients with chronic conditions, limited functional status, or psychosocial needs. This toolkit can help improve an existing care management program or launch a new one.
This brief guide from the American Academy of Family Physicians (AAFP) outlines how risk stratification works, and how it can help providers focus attention on the population of patients who can most benefit from care management.
Nine things physicians and teams need to understand about risk stratification as suggested by co-authors Patrick Gordon (executive director of the Colorado Beacon Consortium) and Asaf Bitton, MD (primary care physician and senior advisor to CMS' Comprehensive Primary Care initiative).