Provide longitudinal care management to patients at high risk for adverse health outcome or harm that could include one or more of the following:
- Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts. Monitor the risk-stratification method and refine as necessary to improve accuracy of risk status identification;
- Use a personalized plan of care for patients at high risk for adverse health outcome or harm, integrating patient goals, values and priorities; and/or
- Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients.
ObjectiveImprove health outcomes and patient-centeredness of care for patients at high-risk for adverse health outcomes or harm.
Evidence of longitudinal, or relationship-based, care management of patients at high-risk for adverse health outcomes as defined by the eligible clinician. Include both of the following elements:
1) List of high-risk patients – Identification of patients at high-risk for adverse health outcome or harm; AND
2) Use of longitudinal care management – Documented use of longitudinal care management methods including at least one of the following: a) empaneled patient risk assignment and risk stratification into actionable risk cohorts; b) personalized care plans for patients at high risk for adverse health outcome or harm; or c) evidence of use of care managers to monitor and coordinate care for highest risk cohorts.
A cardiologist practice learns that a high percentage of their congestive heart failure (CHF) patients are being re-admitted to the hospital within 30 days of a previous admission for CHF. The cardiology group undertakes practice changes to minimize total CHF hospital admissions. Initially, they identify their population in a manner most appropriate to their practice. Examples might include the stage of CHF or patients with any hospital admission within a certain period of time. Then they team with their nursing staff to create a plan that includes an initial discussion with each patient and plans for monitoring weight and diet daily and on a regular basis by phone, email, or electronic medical record patient portal. Additionally, the patients in the cohort are given access to a direct nursing phone line for questions or with specific concerns such as sudden weight gain. An example of a goal would be identification of sudden weight gain with subsequent temporary increases in diuretic dosing, all completed at home.