Enterprise Care Management Patient Stratification
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Solution Overview
Problem
Care managers face challenges in providing effective care management due to fragmentation of patient care across multiple venues and lack of access to comprehensive health records, with traditional solutions relying on incomplete insurance claims data that is retroactive and limited in scope.
Innovation Solution
An enterprise care management solution that compiles and processes health data from disparate sources to identify, stratify, and prioritize patients for care management services, using a cloud computing platform to aggregate electronic medical records and insurance claims data, and align patients with suitable care managers while generating outreach events.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of manufacture
If traditional enterprise care management solutions rely exclusively on insurance claims data to determine patient eligibility for care management services, then the implementation process is simplified, but the identification timing is delayed and the patient profile completeness deteriorates
Solution Approach 1:
The system proactively identifies patients who may benefit from care management services by analyzing health data before they become high-risk cases, enabling early intervention. The care management service continuously monitors patient data from multiple sources and flags patients meeting eligibility criteria before their condition deteriorates or costs escalate.
Solution Approach 2:
The system segments patient identification into multiple independent criteria: health data from electronic medical records, insurance claims data, and social determinants of health. Each data source is processed separately through its own pipeline, then integrated to form a comprehensive patient profile, allowing timely and accurate identification.
2Device complexity
If traditional solutions use only insurance claims data, then data processing is simpler, but the patient profile completeness and accuracy deteriorate
Solution Approach 1:
The system merges multiple previously siloed data sources including electronic medical records, insurance claims data, and social determinants of health into a unified patient profile. This integration creates a comprehensive view of patient health status, risk factors, and care needs that no single data source could provide alone.
Solution Approach 2:
The care management service is designed to process and analyze multiple types of health data through a universal platform that handles electronic medical records, claims data, and social determinants. This multi-functional system can adapt to different data formats and sources while maintaining consistent analysis and eligibility determination.
3Ease of operation
If care managers have access to health data from only one care venue, then data accessibility is improved, but the longitudinal patient record completeness deteriorates
Solution Approach 1:
The system introduces a centralized care management service as an intermediary that aggregates health data from multiple care venues including hospitals, clinics, and home health services. This intermediary platform standardizes and integrates data from disparate sources, providing care managers with a unified longitudinal patient record that spans the entire care continuum.
Data Source
AI summary
Methods, systems, and computer-readable media are provided for identifying, stratifying, and prioritizing patients who are eligible for care management services. For each patient, patient health data is used to determine one or more of a disease burden associated with the patient, an amount of health system utilization by the patient, and an amount of money spent on healthcare services for the patient. It is further determined if the patient exceeds a respective threshold value associated with each of these criteria. If the patient exceeds the respective threshold value, the patient is stratified into a category comprising one of high-risk senior, high-risk adult, high-risk pediatrics, or high-risk maternity. The patient may also be prioritized based on one or more factors, and a notification may be sent to the patient informing the patient of his/her eligibility for care management services.