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Incorporating Social Data into Risk
Stratification Models to Improve Health
Equity and Demonstrate Value
PCA HCCN Conference
San Diego, CA
November 18, 2019
© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary
information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information.
Michelle ProserDirector of Research
National Association of Community Health [email protected]
Performance Accountability
76% of health centers could receive financial incentives for achieving certain clinical care targets
58% of health centers participating in a financial incentive program use an SDOH screening tool*
Commonwealth Fund 2018 National Survey of Federally Qualified Health Centers,
https://www.commonwealthfund.org/publications/surveys/2019/apr/2018-national-survey-federally-qualified-health-centers
*Preliminary finding based on NACHC analysis
Positioning Health Centers For Sustainability
• Funders and stakeholders hold health centers accountable
• More shifts towards value-based payment
• Greater demands for evidence of impact
• Growing competition
• Health centers’ unique model of care of care positions them to address the SDH
• Need for tools to
• Stratify patients by social risks to address these risks
• Document patient complexity and demonstrate value
What Is PRAPARE?
A national standardized patient risk assessment protocol built into
the EHR designed to engage patients in assessing and addressing
social determinants of health
Assess Needs →At the Patient and Population Level
Customizable Implementation and Action Approach
Respond to Needs
© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association.
From Patient to Policy Level
for insured and uninsured patients
Incorporating Social Data into Risk Stratification Models to
Improve Health Equity and Demonstrate Value
© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association. PRAPARE and its resources are proprietary
information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute this information.
Rosy Chang Weir, Director of Research
Association of Asian Pacific Community Health Organizations
PCA/HCCN Conference
November 2019
Definitions
Risk stratification: process or tool for identifying—and predicting—which patients are at high risk—or likely to be at high risk—and prioritizing the management of their care in order to prevent worse outcomes (care team, clinic level)
Risk adjustment: method to offset the cost of providing health insurance for individuals who represent a relatively high risk to insurers (policy, payment level)
“Risk Stratification is an intentional, planned and proactive process carried out at the practice-level to effectively target clinic services to patients.”
Agenda
Slide from Hardin, Trumbo & Murray Presentation - November 2019
National Academy of Medicine’s Vital Directions for Health and Health Care (Blumenthal et al., 2016)
“It is clear that effective tools, care models, and policies must extend beyond strictly medical approaches to address social and behavioral factors…
Payers and health systems…need to divide patients into groups that have common needs so that specific complex care-management interventions can be targeted to the people who are most likely to benefit.”
Addressing clinical needs alone will not improve outcomes or cost:
Why Risk Stratification?
Identify high-risk, high cost patients
Understand reasons why patients are high-
risk, high-cost
Match patients to appropriate
interventions to provide higher quality
care
Inform how to allocate needed resources to care teams, including
prioritizing team workloads
Inform types of staff training needed for
managing care
Identify manageable panel sizes for care
managers/teams
Learning Collaborative Objectives
1. Help participants and national PRAPARE team better understand and assess potential risk stratification strategies and possible pathways toward a common national standardized approach with options for localized methodologies
2. Help the national PRAPARE team understand how organizations apply and use risk stratification as a strategy for improving population health
3. Help participants identify best practices and lessons learned as well as resources to improve organizations’ capacity to apply risk stratification methodologies
Learning Collaborative Participants—Thank You!
CPCA w/ CCALAC, CHP
and NEVC (California)
Iowa PCA/Siouxland
Community Health
Community HealthNet, Inc.
(Indiana)
Charles B. Wang CHC (New York)
Missouri PCAWaianae Coast
Comp CHC (Hawaii)
Compass Community
Health (Ohio)
Callen-Lorde CHC (New
York)
STRIDE CHC (Colorado)
Learning Collaborative Anticipated Outcomes
• Learn from organizational best practice risk stratification methods
• A core national standardized risk stratification method (with optional measures/methods that can be tested with PRAPARE data
• A plan to test the risk stratification method + potential future proposal concept
• Development of national webinar/publication on best practices and lessons learned
Learning Collaborative Meetings
Session TopicSession 1: Overview of Risk Stratification Using SDH Data
Session 2: Approaches to National PRAPARE Risk Stratification
Session 3: Stakeholder Input on PRAPARE Risk Stratification Model
Sessions 4 and 5: Results of PDSAs of PRAPARE Risk Stratification Model
InPerson Meeting: Review, reach consensus on, and finalize the PRAPARE risk
stratification national model incorporating social determinants of health data,
particularly the measures and metrics within each component
IN-PERSON RISK STRATIFICATION MEETING
Meeting Outcomes:
• A stakeholder-vetted national PRAPARE risk stratification model with local options
• Use cases for the national model and local options
• List of targeted interventions by risk group
• Recommendations for reporting and visualization of the risk stratification model
• Considerations for next steps for health centers nationally
As You Think Towards a National Model, Consider…
1-2 Core Principles for Risk Stratification That We Should Lift Up
• Use multiple sources of data• Balanced model that includes separate buckets for SDH, clinical, behavioral, utilization,
that culminates in overall risk score• Automated Process
• The need for reliable data (HIE, SDH data collection, etc.)
• Importance of buy-in from care team• Flexibility to allow for provider/care team input to adjust level of patient risk• Flexibility in using model at clinic level based on resources and staff
• Perfection is the enemy of good. Move forward so have starting point with majority consensus and can always modify over time.
• Use metrics that apply to every person regardless of gender.
RISK STRATIFICATION CROSSWALKLearning Collaborative Team by Component
Learning Collaborative Team
National
Model
Component
Callen-
Lorde
CHC
(New
York)
Charles B.
Wang CHC
(New York)
Community
HealthNet,
Inc.
(Indiana)
Compass
Community
Health
(Ohio)
CPCA w/
CCALAC,
CHP and
NEVC
(California)
Iowa
PCA/Siouxl
and
Community
Health
Missouri
PCA
STRIDE
CHC
(Colorado)
Waianae
Coast
Comp CHC
(Hawaii)
Clinical X X X X X X X X
Mental Health/
Substance
Abuse
X X X X X X
SDH X X X X X X X X
UDS
demographic
X X X X X X X X
Utilization X X X
Lab Results X X
PRAPARE Learning Collaborative Risk Stratification Model, Draft 4
Target population Complex patients based on general population of adult patients
Top Risk Stratification
Goals
1. Identify complex patients to facilitate appropriate interventions primarily for clinic use (clinical/community)
2. Demonstrate the complexity of patients (policy)
Data sources
including PRAPARE
SDH data used (see
detail slide)
Predictor Variables
1. Clinical
2. Behavioral Health
3. SDH
4. Demographics
5. Utilization
Outcome Variables
4. Cost
5. Medications
Risk Stratification
Process/Steps
1. Compile data from active patients having a visit in the past one year
2. Assign a score for each data component, using most recent 1-yr patient data
3. Combine and calculate total risk scores for each data component
4. Sort by total risk score and stratify patients into risk groups using standard deviations
5. Clinic team huddles to validate the risk groups (e.g., Did patients fall into expected groups?),
accounting for clinic/community characteristics (e.g. capacity for interventions, strong community
interventions) and patient characteristics (e.g., ability to manage risk, benefit, acceptability)
6. Target interventions based on the risk groups
Risk stratification
groups
1. Urgent Risk (2 Standard Deviations above Mean Risk Score)
2. High Risk (Between 1 Standard Deviation and 2 Standard Deviations above Mean Risk Score)3. Average Risk
4. Low Risk
Resources provided to
risk groups
1. Intensive care coordination
2. Community health worker intervention (community referrals) with closed loop follow-up
3. Community referrals without closed loop follow-up
Clinical (5 max)
•Number of total chronic conditions that fall in 17 UDS and CCC high-risk clinical conditions
Mental Health/SubAb (5 max)
•Number of total mental health/substance abuse conditions that fall in 7 UDS and CCC high-risk conditions
SDH (5 max)
•Number of SDH Risks
Demographics (5 Max)
•Number of UDS demographic risks
Utilization (5 Max)
Cost High Risk Medications
21
NATIONAL PRAPARE RISK STRATIFICATION, DRAFT 4
Measure
Specs(see also
risk
calculator
spread-
sheet)
Source: Most recent UDS and CCC
model (see Calculator for detailed
codes): 1.Cancer (codes for Metastatic
Cancer and Acute Leukemia, Lung and
Other Severe Cancers, Lymphoma
and Other Cancers, Colorectal,
Bladder, and Other Cancers, Breast,
Prostate, and Other Cancers and
Tumors) 2.Heart
Disease/Cardiovascular Disease
(CVD) 3.Exposure to Heat or Cold
4.Hepatitis B 5.Hepatitis C 6.HIV
7.Lack of Expected Normal
Physiological Development 8.Otisis
Media and Eustachian Tube Disorders
9.Contact Dermatitis and Other
Eczema 10.Syphilis and Other
Sexually Transmitted Diseases
11.Tuberculosis (TB) 12.Abnormal
Cervical Findings 13.Abnormal Breast
Findings 14.Chronic Lower Respiratory
Diseases and Asthma 15.Diabetes
16.Hypertension 17.Obesity
1 condition = 1
2-3 condition = 2
4-5 conditions = 3
6-7 conditions = 4
8+ conditions = 5
Source: Most recent UDS and CCC
model (see Calculator for detailed
codes)
- Depression and other mood
disorders
- Anxiety disorders including PTSD
- Attention Deficit and Disruptive
Behavior Disorders
- Other mental disorders, excluding
drug or alcohol dependence
- Alcohol Related Disorders
- Tobacco use disorder
- Other substance related disorders
(excluding tobacco use disorders)
1 condition = 1
2 condition = 2
3 conditions = 3
4 conditions = 4
5+ conditions = 5
Source: National PRAPARE
General Population Data (excluding
UDS demographic categories of
race, ethnicity, veteran status,
farmworker status, federal poverty
level, and insurance). See the
"PRAPARE Risk Responses" tab in
the excel risk calculator for the
positive or "high risk" responses.),
1 SDH risks = 1,
2 SDH risks = 2,
3 SDH risks = 3,
4 SDH risks = 4,
5+ SDH risks = 5
Source: Most recent UDS
Number of demographic risks from
UDS data (race, ethnicity, veteran
status, farmworker status, federal
poverty level, insurance). See the
"PRAPARE Risk Responses" tab for
the positive or "high risk" responses.
1 demographic risk = 1,
2 demographic risks = 2,
3 demographic risks = 3,
4 demographic risks = 4,
5-6 demographic risks = 5,
Source: MO Medicaid
1 ER visit or inpatient
hospital stay = 1
2 ER visits or inpatient
hospital stays = 2
3 ER visits or inpatient
hospital stays = 3
4 ER visits or inpatient
hospital stays = 4
5+ ER visits or
inpatient hospital stays
= 5
LOCAL
OPTION
Number of total chronic
conditions as prioritized by
clinic
Number of total mental
health/substance abuse
conditions as prioritized by
clinic
Number of SDH risks as
prioritized by clinic
Number of UDS
demographic risks as
prioritized by clinic
Number of ER
visits or inpatient
hospital stays as
prioritized by clinic
PROS Uses UDS + NACHC
national standards
Uses UDS national
standards
Uses current national data Uses current national data Uses current ACO
standards
CONS Does not include all
conditions to identify risk
for all patients, only
UDS/CCC
Does not include all
conditions to identify risk for
all patients, only UDS
Relies on comprehensive
PRAPARE administration
Relies on comprehensive
administration of UDS
demographic questions
Data not widely
available
Predictors: Clinical + Mental Health/Substance Abuse + SDH + Demographics + Utilization Outcomes
See Next Slide
•Number of ER
Visits OR
Inpatient stays
22
Clinical Component
Number of total chronic conditions that fall in 17 UDS and CCC high-risk clinical conditions
Measure
Specs
(Detailed codes in
Risk Calculator)
(Reference:
NEVHC)
Source: Most recent UDS, ICD10, Chronic Condition Count (CCC) model1. Cancer (codes for Metastatic Cancer and Acute Leukemia, Lung and Other Severe Cancers, Lymphoma and
Other Cancers, Colorectal, Bladder, and Other Cancers, Breast, Prostate, and Other Cancers and Tumors)
2. Heart Disease/Cardiovascular Disease (CVD)
3. Exposure to Heat or Cold
4. Hepatitis B
5. Hepatitis C
6. HIV
7. Lack of Expected Normal Physiological Development
8. Otisis Media and Eustachian Tube Disorders
9. Contact Dermatitis and Other Eczema
10. Syphilis and Other Sexually Transmitted Diseases
11. Tuberculosis (TB)
12. Abnormal Cervical Findings
13. Abnormal Breast Findings
14. Chronic Lower Respiratory Diseases and Asthma
15. Diabetes
16. Hypertension
17. Obesity
Scoring
(Max score = 5)
1 condition = 1
2-3 condition = 2
4-5 conditions = 3
6-7 conditions = 4
8+ conditions = 5
LOCAL OPTION Number of total chronic conditions as prioritized by clinic
23
Measure
Specs
(Detailed codes in Risk Calculator)
(Reference: NEVHC)
Source: Most recent UDS, ICD10, Chronic Condition Count (CCC) model
1. Depression and other mood disorders
2. Anxiety disorders including PTSD
3. Attention Deficit and Disruptive Behavior Disorders
4. Other mental disorders, excluding drug or alcohol dependence
5. Alcohol Related Disorders
6. Tobacco use disorder
7. Other substance related disorders (excluding tobacco use disorders)
Scoring
(Max score = 5)
1 condition = 1
2 condition = 2
3 conditions = 3
4 conditions = 4
5+ conditions = 5
LOCAL OPTION Number of total mental health/substance abuse conditions as prioritized by clinic
Mental Health/Substance Abuse Component
•Number of total mental health/substance abuse conditions that fall in 7 UDS and CCC high-risk conditions
24
Measure
Specs
(Detailed codes in Risk Calculator)
Source: PRAPARE General Population Data (excluding UDS demographic categories of race, ethnicity, veteran status, farmworker
status, federal poverty level, and insurance)Limited English proficiency
Housing status
Housing stability
Education
Employment
Insurance status
Income as a percentage of Federal Poverty Level
Food security
Utilities security
Childcare security
Clothing security
Phone security
Medicine or health care security
Other material security needs
Transportation for medical needs
Transportation for non-medical needs
Social integration/isolation
Stress
Scoring
(Max score = 5)
See the "PRAPARE Risk Responses"
tab in the PRAPARE Risk Calculator
1 SDH risks = 1,
2 SDH risks = 2,
3 SDH risks = 3,
4 SDH risks = 4,
5+ SDH risks = 5
LOCAL OPTION Number of SDH risks as prioritized by clinic
Social Determinants of Health (SDH) Component
•Number of PRAPARE SDH Risks
How is PRAPARE SDH risk scored?
Response Categories for PRAPARE Core Measures PRAPARE Tally Points by Response Category
Housing Situation: What is your housing situation today? (maximum of 1 tally)
I have housing 0
I do not have housing 1
Housing Stability: Are you worried about losing your housing? (maximum of 1 tally)
Yes (unstable housing) 1
No (stable housing) 0
Education: What is the highest level of school that you have finished? (maximum of 1 tally)
Less than high school degree 1
High school diploma or GED 0
More than high school 0
Employment: What is your current work situation? (maximum of 1 tally)
Unemployed and seeking work 1
Part-time work 1
Full-time work 0
Otherwise unemployed but not seeking work 0
Material Security: In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? (Check all that apply.) (maximum of 7 tallies)
Food 1
Clothing 1
Utilities 1
Child care 1
Medicine or health care 1
Phone 1
Other (enter written answer) 1
No unmet needs 0
Examples – More detail can be found in PRAPARE National Model Risk Calculator
26
Measure
Specs
(Detailed codes in Risk Calculator)
Source: Most recent UDS
Number of demographic risks from UDS data:
Race
Ethnicity
Veteran status
Farmworker status
Federal poverty level
Insurance
Scoring
(Max score = 5)
1 demographic risk = 1
2 demographic risks = 2
3 demographic risks = 3
4 demographic risks = 4
5-6 demographic risks = 5
LOCAL OPTION Number of UDS demographic risks as prioritized by clinic
Demographics Component
•Number of UDS demographic risks
27
Measure
Specs
(Detailed codes in Risk Calculator)
Reference: MO PCA Medicaid
ACA Section 2703 Health Home
Initiative
Source: Payer Data
Emergency CPT codes - 99283, 99284, 99285, 99281, 99282
Hospital Inpatient CPT Code range 99221- 99239
Scoring
(Max score = 5)
1 ER visit or inpatient hospital stay = 1
2 ER visits or inpatient hospital stays = 2
3 ER visits or inpatient hospital stays = 3
4 ER visits or inpatient hospital stays = 4
5+ ER visits or inpatient hospital stays = 5
LOCAL OPTION Number of ED visits or inpatient hospital stays as prioritized by clinic
Emergency Department Utilization Component
•Number of ED Visits OR Inpatient stays
Cost (5 max)
• If or not the patient is among the top 5% in terms of total cost of care
High-risk Medications (5 max)
• Number of high-risk medications
28
NATIONAL PRAPARE RISK STRATIFICATION, DRAFT 4, CONTINUED
Measure
Specs
(see also risk
calculator
spreadsheet)
Source: Payer Data (Source: Pharmacy Data, if the patient is taking 5 or more high risk
medications as indicated with ICD10 code Z79- Long term (current) drug
therapy by daily)
LOCAL OPTION If or not patient is among top 5% of clinic’s priority costs of care If the patient is taking 5 or more high-risk medications as prioritized by
clinic
PROS Priority indicator/outcome for complex patients Priority indicator/outcome for complex patients
CONS Data not widely available, may be duplicative of ER utilization Data not widely available, experimental, duplicative
Outcomes (used for validation of risk model): Cost and/or Medications
Calculation of Components and Total Risk Score
Component Score Range Weight
Clinical 0-5 20%
Mental Health / Substance Abuse 0-5 20%
SDH 0-5 20%
Demographic 0-5 20%
ED Utilization 0-5 20%
Total Risk Score 0-25 100%
Risk Groups
1. Urgent Risk = Higher than 2 Standard Deviations above Mean Risk Score
2. High Risk = Between 1 Standard Deviation and 2 Standard Deviations above the Mean Risk Score
3. Moderate Risk = Between the Mean and 1 Standard Deviation above Mean Risk Score
4. Low Risk = Lower than Mean Total Risk Score
COMPARISON OF POPULATIONS WITH DIFFERENT MEAN TOTAL SCORES AND STANDARD DEVIATIONS
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Pro
ba
bili
ty
Total Score
Example 1: Distribution of A Population with Mean Score = 10, SD = 7
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Pro
ba
bili
tyTotal Score
Example 2: Distribution of A Population with Mean Score = 13, SD = 3
High Risk:17-24
HighRisk:
16-19
UrgentRisk:>24
Urgent Risk:>19
Mean Score= 10
Mean Score= 13
SD = 7 SD = 7
SD=3
SD=3
Moderate Risk:10-16
ModerateRisk:
13-15
Risk Stratification Process
Compile data from active patients having a visit in the
past one year
Assign a score for each data component, using most recent
1-yr patient data
Combine and calculate total risk scores for each data
component for each patient
Sort by total risk score and stratify patients into risk groups using standard
deviations
Clinic team huddles to validate the risk groups (e.g., Did patients fall into
expected groups?), accounting for clinic/community characteristics (e.g.
capacity for interventions, strong community interventions) and patient characteristics (e.g., ability to manage
risk, benefit, acceptability)
Target interventions based on the risk groups
Interventions for Risk Groups
• Still TBD
Higher Risk Average Risk Lower Risk
• Intensive care coordination• Closed loop referrals with follow-
up• Different staff involved• Patient Navigation• Case management• Home visitation• Longer visit time?• More hands-on care?
• Interventions for unhealthy behaviors• Health education• Shared medical visits for self-
management
• Preventive screening• Group health education• Links to community resources
without closed loop follow-up
What if you don’t have complete data?
• Participants should ideally use comprehensive data for all components where possible for best prediction.
• If data is unavailable for specific data component, risk can still be calculated but may not be as precise. Since risk score is based on mean and standard deviation, risk score is relative to your own patient population data.
• What about incomplete PRAPARE data?
Potential Strategies to Handle Incomplete PRAPARE Responses
Strategy Consider incomplete response as “no
risk” (score=0)
Consider incomplete response as the
average of the rest of the scores (score =
mean of the rest)
Example: 6 risks out
of 21, with 3 left
blank
Score of blank questions = 0;
Total score = 6
Score of blank questions = 6/18 = 0.33;
Total score = 6 + 0.33*3 = 6.99 ≈ 7
Pro Simple, no need for additional calculation Able to amend incomplete responses
Con SDH risk of patients with incomplete
responses would be underestimated;
Potential bias towards patients with
complete responses
Additional calculation required;
Potential bias towards questions where
blank mostly means “no risk” such as
migrant farm worker or veteran
**Participants should ideally use comprehensive PRAPARE responses where possible for best prediction.
If data incomplete, participants can use a combination of the two strategies above: Based on your patient
population, identify the questions where a blank response mostly means “no risk”, set blank responses for these
questions to 0, then use the second strategy on the rest of the questions.
PRAPARE National RISK Stratification Model CALCULATOR
PRAPARE Learning Collaborative, Draft 2B PDSA Results
TeamTotal number of
testing sample
Number identified as
"High Risk" or
"Urgent Risk" by the
algorithm
Number validated as
correct
% of High or Urgent
Risk % of correct
1 6 6 6 100% 100%
2 18 13 8 72% 62%
3 6 4 4 67% 100%
4 10 9 7 90% 78%
5 10 10 10 100% 100%
6 30 18 11 60% 61%Total N/
Average % 80 60 46 75% 77%
How would this look in clinic systems?
Automated Scores from Clinic
High Risk Patient Prediction
Risk Component
Patient's Risk
Score in Each
Component Notes
Clinical Score 3
Mental Health / Substance Abuse Score 2
PRAPARE SDH Score 3
Demographics Score 2
ER Utilization Score 3
Patient's Total Risk Score 13
PRAPARE Risk Stratification Example Visualization
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Non-High Risk Group Average
High Risk Group Average
Urgent Risk Group Average
Comparative Groups Risk
Scores
Patient's Total Risk Score
Patient Total Risk Score
Urgent Risk Average Score
High Risk Average Score
Non-High Risk Average Score
Modeled after Framingham Risk Visualization
Principles for Risk Stratification Model
Intended to inform but not replace clinical judgment
Encourage use of a hybrid approach using quantitative data for the risk algorithm and qualitative data from clinical staff judgment
Simple, easy to use Low-tech
Risk factors organized in categories to better
understand aspects of each component for each
patient
Uses a point system to make the complex model useful at the point of care
a.Higher score = higher risk patient
b.Range is 0 to 25, 5 for each component
Uses standard deviation to define risk tiers to account for risk scores relative to all other patients in the population/denominator
Why a local option?
• Vary SDH risk model based on local situations
• Primary difference from National Model: Vary the criteria of components based on local situations
• Asian American network prioritize Hepatitis B conditions as opposed to all conditions in Clinical Component
• Local area without good housing resources prioritize homeless in SDH component
• Local area with large opioid population weigh mental health component higher
• Various local options for consideration:1. Vary weights of components and subcomponents2. Vary cutoffs of high risk of PRAPARE SDH3. Vary other component cutoffs for urgent and high risk based on resources or
interventions/enabling services available in health center/community
AAPCHO DATA COLLECTION PROTOCOL:THE ENABLING SERVICES ACCOUNTABILITY PROJECT
Enabling Services Accountability Project
(ESAP)
The ONLY standardized data system to track
and document non-clinical enabling
services that help patients access care.
Enabling Service Categories Code
Social Services Assessment SS001
Case Management CM001
Referral- Health RF001
Referral- Social Services RF002
Financial Counseling/Eligibility Assistance FC001
Health Education- Individual (one-on-one) HE001
Health Education- Small Group (2-12) HE002
Health Education- Large Group (13 or more) HE003
Supportive Counseling SC001
Interpretation IN001
Outreach OR001
Inreach IR001
Transportation- Health TR001
Transportation- Social Services TR002
Other OT001
Data Collection Protocol, Handbook, and other resources at:http://enablingservices.aapcho.org
http://EnablingServices.aapcho.org
• Needs Assessment
• Readiness
Assessment
• Workflows
• EHR Integration
• Database Strategy
• Training Guidelines
• Report Cards
ESDC Implementation Companion
Benefits of using the National PRAPARE Risk Stratification Model - LC Perspectives
Improve Care Management and Interventions
• Meet the needs of patients in various risk tiers
• Prioritize and address care management needs that can ensure high-quality and timely care
• Make important decisions including interventions offered based on level of patient risk
• Correctly assign limited staff/resources for the highest risk patients
• Standardize our current care management practice to provide a systematic way to identify patients who need extra attention from the care team
• Define interventions for specific risk tiers to inform how resources should be used
Standardization and Systematic Approach
• Appreciate having a standard format to compare with others nationally
• Having a systematic approach to gather as much data as necessary to increase confidence in interventions by key stakeholders and staff
• Encourage uniform metrics and common methods/source of collecting the data
• Use of a universal framework with national aggregated data will allow great knowledge sharing & communication
• Easier to troubleshoot as unanticipated problems arise if all sites use the same model
Demonstrate Complexity of Patients
• Illustrates the complexity of our patients’ biopsychosocial conditions
• Build a fuller picture of intervention target needs for our most complex patients
Benefits of using the National PRAPARE Risk Stratification Model (continued)
Inform Value-based Care and Cost Savings
• Prepare us nationally for value-based payments
• Decrease total cost of care and improve outcomes for patients by focusing efforts on highest utilizers
• Develop low touch interventions to meet the needs of those patients identified as low risk tier patients
• Advance value-based care through cross-sector collaboration to improve health outcomes
Qualify for PCMH and Quality Incentives
Inform Payment and Policy
• Opportunity to work with Medicaid regarding most successful strategies to reduce health care costs and improve health
• Inform risk adjustment of social factors that will be key to payment and delivery reform we’re working towards in Missouri
• Development of a network-wide risk stratification methodology across all centers will inform the development of more robust and refined care team and care coordination models as well as provide a set of data to take to payors to inform risk and resource allocation to support care coordination at the health center level
Challenges and Solutions
Challenge SolutionAdequate staffing for implementation of
model
Risk stratification is intended to improve staff resource
allocation including training needs for care management teams
Resources to act on info As with PRAPARE, resources can be improved with increasing
data on high risk patient profile and needs
Data availability, especially for utilization and
comprehensive SDH data
Participants agreed that even with data availability issues, we
should plan our national model based on data being more
widely available in the near future
Complexity of national algorithm when clinics
do not have automated systems
All algorithms are challenging without automation. We
developed a risk calculator in excel, though automation is
highly encouraged.
Obtaining consensus among teams who had
different risk stratification approaches
Teams agreed perfection is the enemy of good. We can always
test and revise. Teams could also use the local model option.
Different clinics/locations may have different
barriers, priorities
Teams can choose to use the local model option
© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association.
Next Steps
• In-person Risk Stratification Meeting to review, reach consensus on, and finalize the PRAPARE risk stratification national model
• PRAPARE national analysis strategy with a plan to test the nationally developed risk stratification model with large patient-level dataset
• Development and dissemination of national webinar/publication on best practices and lessons learned
Save-the-Date!
“Enabling Services Data Collection –
For PCAs” Training by AAPCHO
April 15-16, 2020
Omaha, NE
Hosted by: Health Center Association of
Nebraska (HCAN) and Health Outreach Partners
(HOP)
Questions and Resources for More Information
Visit
www.nachc.org/prapare
Join our listserv!
Email [email protected]
Resources Available to Support Health Centers, PCAs, & HCCNs
✓ PRAPARE Implementation and Action Toolkit
✓ Free EHR templates for Cerner, eCW, Epic, GE Centricity, Greenway, NextGen
✓ 10 translations of PRAPARE including Spanish, Somali, Arabic, Chinese, Tagalog, Korean, Vietnamese, and more! 10 more coming soon!
✓ PRAPARE Readiness Assessments for CHCs & PCAs
✓ Recorded Webinars on PRAPARE, Workflows, EHR Templates, etc.
✓ PCA/HCCN Case Studies Highlighting Successful Strategies
http://EnablingServices.aapcho.org
Incorporating Social Data into Risk Stratification Models
to Improve Health Equity and Demonstrate Value:
California’s PerspectiveLucy Saenz, MPH
Assistant Director of Data InformaticsCalifornia Primary Care Association
California Team
Why Risk Stratification in California?
Improved Provider
Experience
Improved Patient
Experience
Lower Costs
Improved Outcomes
Quadruple Aim Standardized Data
Standardized Data
How PRAPARE positions California for Risk Stratification
• Standardized data at the state, regional and community and patient level
• Comprehensive Assessment with Different Domains
• ResourcesCalifornia Health Centers (Organizations)
PRAPARE Implementation
What CA hoped to achieve out of participating on the learning collaborative?
1. Involve California members in developing, refining, and piloting a collaborative risk stratification process for social needs
2. Support members improve outcomes for patients3. Gain knowledge to spread to all clinics in the state
What CA did to position us for the achievements?
1. Included consortium and health center partners2. Collaborated with California partners to provide input
on the model3. PDSA cycles 4. Health Center feedback is key to the development
Application and Use of the Risk Stratification Model in California
• Benchmarking: National, State and Regional Comparisons
• Community Health Center Patients
• Targeted Patient Care – Meeting Patients where they are
• Spread across the state
Recommendations on How to get Started and Why:
• Collaboration and partnerships are crucial!
• Support health centers with standardizing SDOH data (e.g. PRAPARE)
• Start small and conduct PDSA’s that will help you test the model
For More Information:
Lucy Saenz, MPH
Assistant Director of Data Informatics
Social Determinants of Health Policy and Practice: the Iowa Experience
2019 Tennessee PCA Annual Conference – October 3, 2019
Our Vision and Interest
• Provide better care to patients• Collect more robust data about other factors impacting
health
• Begin to match identified issues with solutions with the health center
• Use data to establish or grow partnerships with other community resources
• Leverage data and accompanying interventions to provide evidence to payors and policymakers about the needs of patients, a broader definition of patient risk, and to ensure adequate reimbursement for safety net providers
• Iowa has 13 health centers and one migrant/farmworker health center
• Two health centers were PRAPARE pilots (Sioux City & Waterloo) and started using the tool in 2014
• Goal is to achieve 100% adoption of PRAPARE across our clinically integrated network (CIN), IowaHealth+
• Six health centers have implemented PRAPARE and four health centers are actively working to implement PRAPARE
• Last CIN member owner health center is migrating to new EMR• Three other health centers are not part of our CIN so outreach from
PCA staff has not occurred
PRAPARE Implementation Update
Sample Tableau Visualizations
1. Incorporating preventive measures/visits and hospital utilization into the methodologya) Preventive screenings not completedb) Patients not regularly coming in for care (another way to look at utilization)c) ED/inpatient visits
2. Social Determinants of Health – transportation as top concern3. Integration of behavioral health
a) More than three BH medicationsb) Medication adherence (should apply on the medical side too)c) Weigh pts. with chronic diseases AND co-morbid BH diagnoses more heavily
4. Weighting of controlled vs. uncontrolled diseases 5. Patient activation/engagement – readiness to change, confidence, literacy 6. What diagnoses would automatically put a patient in a high-risk tier and how do we incorporate provider/care team
discretion?a) Heart failure, kidney failure, diabetes, coronary artery disease, COPD, chronic hypertension, certain BH
diagnoses, Hep C, Sickle Cell7. Incorporation of claims data, including ED utilization for oral health issues, and identifying patients who used the ER
and were admitted to the inpatient setting8. Centers will want to see how different weighting structures influence the patient risk tier mix
Parking Lot – Risk Stratification
1. Risk scoring needs to be automated2. Without universal PRAPARE screening, scoring will be inaccurate3. PRAPARE data needs to be captured accurately4. PRAPARE questions need to be accurately weighted (education, stress, social
isolation, employment)5. Medications for high-risk conditions should be used as a predictive variable to
properly weight medical and behavioral health conditions, not as an outcome variable. ICD-10 should not be used to determine high-risk medications.
6. Total score determines who will benefit from care coordination, individual predictive variables determine which care team member will provide the care coordination.
7. Flexibility based on health center resources, what score and who to manage?
Top Recommendations for National Model
• Appointment length based on risk score
• Provider empanelment
• Provider burnout
• Insurance contracting
Administration/Leadership Considerations
Sarah Dixon, MPA
Chief Strategy Officer
Questions?
@iowapca www.iowapca.org
Hearing from You:
HOW IS RISK STRATIFICATION HELPFUL?
Care managementPopulation health/QI
Community health/partnership
Payment reform, risk adjustment
Clinic Full spectrum patient care System
Identifying individual
patient needs to better
develop treatment plans
Determining populations of
greatest risk for care
coordination
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