Partnering to Lead: FQHCs Drive Quality Patient Care with a

Clinically Integrated Network

Steps to Build a Risk-Stratified Care Management Program

So now let’s talk about steps on how you build a program. We’ve kind of organized this into five sections of work, but I wanted you to note that the provider is at the top of the continuum. We believe that care is done best when it’s done at the PCP level and developing care management strategies that are led by physicians are really the best in the most successful in my experience. Starting off, we wanna look at patient selection, and this is where we identify all the patients that are attributed to your health plan, regardless if they’ve been seen or not, or not. This kind of changes our lens from the patients that are just in our, that just come in for a visit to looking at their entire population. Many times you get this information from health plan eligibility, but there are other forms to receive as well. This is the time that we’re gonna start to stratify your population to understand where all of the patients should be segmented into and who we should focus on first. Another strategy at this step is really to start focusing on the empanelment of your practices and just evenly distributing the pa patient populations to your providers. This is also an opportunity to start shifting to time to visits, how many visits, and looking at strategies to, for outcomes and, and population management tools.

Once we have identified our patients and we’ve stratified them, we can move into the enrollment step of care management. And this is the patient engagement step, and probably the most important. Obviously, if our patients aren’t engaged, we don’t have a lot of effectiveness in deploying very many strategies. So developing methods that we can ensure that patient engagement is secure. Number one is making sure that we have the right phone numbers, right contact information, et cetera. Health plans are really also a good help in helping us discern that information. You know, annual wellness visits are also a really key time to make sure and verify that patient contact information is accurate. The other thing is, is really this is where we talk about physician-led, is having our physicians start driving the conversation and introducing them into those, those care management programs, regardless of what they are, each patient will have, based on their risk, will have a different level of enrollment necessary needed to be participating in care management. For example, for our low-risk patients, enrollment is not necessarily a phone call or a physician handoff. Enrollment may be a text reminding them that their annual wellness visit is due or that their breast cancer screening is dual. Enrollment for maybe a high-risk patient will look different in the sense that those are complex advanced disease type patients, and that may require more of a physician handoff, team huddles, and more collaborative care opportunities that we would see with that segment of patients.

The third step that we outlined is case management. Now, within our populations, not all patients need case management, but it is an important piece, step in the management of the risk of your populations within the high-risk. And high highly risk complex cases. Case management probably is one of the best interventions to the one-on-one intent services, but case management doesn’t always have to be that way necessarily maybe for the low-risk, it’s more of just a coordinated effort or a warm touch at their annual wellness visit. The fourth step in risk strategy building a risk-stratified care management program is coordination. Again, depending on the risk level there, this intensity of intervention is different For low risk, it’s, it may be just coordinating their annual wellness visit and keeping them engaged with your health system for more of the high-risk patients that may be doing more of the referral management pieces, ensuring that the patients get to the right network, ensuring that information flows back to providers, ensuring that care is coordinated between all the specialties and that patients aren’t lost in the system.

The fourth step in a care management program is graduation. It’s probably the most important step, and I, a step that I see gets a, lead or eliminated most often and a graduation step is really that evaluation piece. As we talked about, patients don’t always stay in the same risk segment that we’ve initially identified. So developing strategies to move them into the appropriate risk category as well as to graduate them out of their program. In my experience, case managers like to hang onto their patients for years and years and years. It’s a relationship that they have with them. It’s important, but make sure that the interventions and strategies and the risk that we have identified is appropriate for services.