Predict the future: stratify patients by risk to more effectively coordinate care

As organizations take on more risk, both clinical and financial, they are looking for ways to improve the quality of the care they provide and reduce costs. Population health management (PHM) with a strong emphasis on advanced analytics is one strategy for getting there.

Perhaps more so than any other disease, diabetes can be improved from a cost, quality and patient satisfaction perspective by applying the principles of PHM. For instance, providers can take a closer look at lab criteria such as HbA1c or LDL cholesterol levels to identify patients whose disease is being poorly managed. And that kind of clinical intelligence can help stratify patients by risk and guide the development of care management programs.Jeremy Orr, MD, MPH

One example is the providers at Mid Hudson Medical Group in New York who, after analyzing data, were able to identify which diabetic patients met criteria for proactive outreach. The group was able to single out patients whose HgA1c was greater than 7 percent at their last visit, or who had not been seen by a provider within the last 12 months.

In this group of diabetics:

  • About a third were seen one or more times within the first eight months of the program
  • One-third achieved an HgA1c of less than 8 percent
  • Sixty percent of those with HgA1c higher than 9 percent became more intensively managed through more frequent visits with their primary care physician

In addition to identifying and acting on gaps in care, organizations can use longitudinal data to track clinical, operational and financial performance. Dashboard reports, for instance, can provide valuable insight into clinical performance, laying the groundwork for initiatives designed to promote evidence-based medicine. Blood sugar control, lipid management, foot and eye exams, diligent monitoring for kidney disease—all are components of diabetes care that advanced analytics can report in detail.

For more information, download our free e-book: Playbook: Maximize the value of your diabetes population management program with advanced analytics.

–Jeremy Orr, MD, MPH, Chief Medical Officer, Optum Analytics

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