rising risk: early insights into preventing complexity · rising risk: early insights into...
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Advancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income Americans
www.chcs.org | @CHCShealth
Rising Risk: Early Insights Into Preventing Complexity
Putting Care at the Center Annual Conference
November 13‐15, 2019
Caroline Cawley, Rachel Davis, Sarah Stella, and Jonathan Weedman
Today’s Presenters
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Caroline CawleyResearch AssociateUniversity of California, San Francisco
Sarah StellaAssociate Professor of Medicine, HospitalistDenver Health
Rachel DavisDirector, Complex PopulationsCenter for Health Care Strategies
Jonathan WeedmanVice President, Population HealthCareOregon
About the Center for Health Care Strategies
A nonprofit policy center dedicated to improving the health of low‐income Americans
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Complex Care Innovation Lab:» 13 leading organizations throughout the country focused on designing, delivering, and spreading innovative approaches to complex care
»Funded by Kaiser Permanente Community Health and the Robert Wood Johnson Foundation
Subset of these members have spent the last year thinking about Rising Risk
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CHCS Rising Risk Initiative
» Boston Health Care for the Homeless Program (MA)
» Camden Coalition of Healthcare Providers (NJ)
» CareOregon (OR)» Center for Health Care Services (TX)
» Denver Health (CO)» Johns Hopkins HealthCare (MD)» University of California, San Francisco (CA)
Why Rising Risk?» Complex care to date has largely focused on supporting individuals who already have intensive medical and social needs and high costs
» Stabilizing individuals who are on the trajectory to becoming complex‐ but aren’t there yet‐ holds promise for improved quality of life, care and savings
Key Questions:»How do you identify an impactable Rising Risk population?» What are the key characteristics of a Rising Risk population?» What are the key modifiable forces driving their risk?» What interventions are best suited for this population?
Rising Risk Overview
Would you consider this individual to be Rising Risk?» Why or why not?» Is there additional information you would want to have in order to make this determination?
If yes, what are the major forces contributing to rising risk for him or her?»Which of these would you prioritize focusing on and why?
What interventions would you link this person to?» How are these different from interventions designed for individuals who are already medically and socially complex, and how are these the same?
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Group Exercise: Discussion Questions
www.chcs.org | @CHCShealth
Advancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income Americans
Panel Discussion
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Who we are: Medicaid and Medicare serving organization founded in 1994»250K lives»Covers urban and rural areas in Oregon»Tribal Care Coordination contract with the state»In Home Primary Care Provider/Hospice and Palliative Care
Rising Risk cohort: Descriptive in nature and segmented into four groups‐ Chronic Managed, Complex Managed, Uncoordinated, Chronic Uncoordinated
Identification approach: Cluster analysis with an ACG backbone. Inputs include medical claims, pharmacy claims, utilization data, and demographic data
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CareOregon
Who we are: Fully integrated safety net health care system with hospital, network of community health centers, EMS, public health and health plan»Serves predominantly urban, un‐ or underinsured and low income populations
»25,000 admissions and 500,000 outpatient visits annually
Rising Risk cohort: Adult managed care Medicaid patients experiencing homelessness
Identification approach: Utilized established population segmentation strategy based on CRG and utilization (‘Tiering’) plus claims data to identify
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Denver Health
Who we are: Evaluators of San Francisco Whole Person Care:»Five‐year Medi‐Cal waiver pilot program, led by the San Francisco Department of Public Health
»Goal: improve outcomes for adults experiencing homelessness and frequent use of acute care services
Rising Risk cohort: includes users of any urgent or emergency service (medical, mental health or substance use disorder) in SF system of care
Identification approach: Developed model to identify factors (demographics, diagnoses, utilization patterns) associated with increased service utilization in subsequent years10
University of California, San Francisco
www.chcs.org | @CHCShealth
Advancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income AmericansAdvancing innovations in health care delivery for low‐income Americans
Audience Question& Answer
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