In a recent post, we discussed usability factors in predictive analytics. Today’s final post in the predictive analytics series will discuss an example of a provider that has used prediction to inform its population health management program.
Predicting hospitalizations helps Sentara practice proactive care. Sentara Medical Group has 380 primary and specialty care physicians in Virginia and North Carolina. They have received the NCQA’s highest level of recognition for their Patient Centered Medical Home (PCMH) program. To help identify PCMH patients at risk of hospital admission, they use Optum One—an analytics and care management platform.
Specifically, Sentara uses Optum One’s predictive analytics to find and stratify patients with congestive heart failure, chronic obstructive pulmonary disease (COPD) and diabetes. At the outset of using Optum One, Sentara selected 11 pilot sites. Then, Sentara’s quality team used predictive analytics to pinpoint a small number of high-risk patients for each site. The quality team shared detailed patient information with each site, which provided a 36-month view of an individual patient’s clinical statistics (e.g., BMI, blood pressure, ejection fraction), utilization (e.g., ER visits), and treatments (e.g., medication updates). This information helped physicians recognize and act on gaps in patient care or changes in health status.
Results from predictive analytics show promise. Physicians appreciate the analytics information. Rates of engagement in care coordination programs have improved, attaining more than 50 percent of eligible patients in some cases. Sentara is expanding its use of predictive analytics to the remaining PCMH sites as well as introducing the pediatric asthma model as an additional tool.
Sentara is one of many providers beginning to integrate predictive analytics into their organizations. They are using it to help rebalance their care model in favor of more proactive care. By honing in on high-risk patients sooner and with more accuracy, providers can focus their resources where they will have the highest impact, and succeed in an environment rapidly moving toward value-based health care.
For more on how you can use predictive analytics to improve your population management programs, download this Optum white paper.