Typically, a healthcare organization’s rationale for stratifying the distinct segments of its patient population is closely associated with its modern care management model’s patient assignment decision-making.
But whatever the risk stratification option used to determine specific populations, the resulting patient segments enable the health enterprise or practice’s staff to tailor the provision of care to both the individual’s and population’s unique needs and challenges.
Let’s review the range of patient segmentation options available that determine how most care management team members are assigned. Keep in mind, there are tradeoffs related to efficiency, ease of patient outreach, and relationships with others on the care team depending on which segmentation model you choose.
Diagnosis: Many healthcare administrators assign care staff resources to patients by diagnosis. For example, a diabetes-specific population might have an assigned diabetes coach. Or, patients diagnosed with or at risk of coronary heart disease, especially as the U.S. experiences a demographic shift toward an older population, might be assigned a heart failure specialist to optimally target preventive efforts.
Level of Risk: Other facility leaders might assign care team members to patients based on level of utilization risk based on predictive modeling, typically categorized as high, rising, moderate and low. One literature review points out that studies have found “high-need, high-cost” patients account for almost 50% of healthcare spending despite composing just 5% of total patients. It may therefore make sense to apportion care team resources unevenly so that these complex cases receive greater attention, allowing personnel and other resources to be utilized to their utmost productivity.
Payer: Because care management can be a costly investment, some organizations organize services based on payer contracts. They may wall off services to those patients they’re reimbursed for under pay-for-performance or risk-based payment models.
Provider: Care managers can be assigned patient panels based on groups of practices that have a larger portion of target patients. This enables individual care managers to consistently work with the same outpatient clinicians and powers continuous relationships between patients and their care providers.
Setting: Members of an interdisciplinary care management team represent different settings of the care continuum - from primary care to home healthcare, a skill nursing facility and more– to maximize shared care planning and care coordination services and technologies. Drawing from these resources, providers can select the best solutions for every patient cohort across a team of professionals to foster positive health outcomes and reduce costs.
With that in mind, we at the Advisory Board have researched best practice models that start with risk stratifying the population based on a mix of clinical, psychosocial and claims data (as well as provider intel). From there, ambulatory-based care teams can be separated first by primary care versus specialty practices.
For most primary care patients, I recommend segmenting them by a single medical practice if there are enough target patients empaneled at that practice. If not, you can pod a grouping of practices within a geographical region. Lastly, if you have the resources, I recommend further segmenting patients into high risk and rising/moderate risk groups. Throughout this process, the care manager should work with no more than three practices regardless of patient workload in order to remain attentive to care coordination activities at hand.
In summary, provider leaders at the forefront of deploying new modern care management models must move beyond solely focusing on high-risk patients and take a more holistic approach examining all health and wellness levels of their patient populations. An important starting point is the identification of patient segments whose diverse needs will dictate the assignment of skilled medical professionals to the appropriate care teams.
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