Risk stratification: Drive value-based healthcare and the Triple Aim with smart algorithms

Risk stratification: Drive value-based healthcare and the Triple Aim with smart algorithms

Consultation hours are overly busy, and a lot of time goes into checking off the required boxes. It drives healthcare providers crazy! Understandable, but unnecessary. With a different focus and approach, there is a lot to be gained in terms of the Triple Aim. The secret is to look at risks instead of diseases and making smart use of your own data through algorithms, also known as risk stratification. In this blog we will explain how you can organize your care based on patient groups with high, increased or low risk profiles. We will show you that it leads to: 1) better outcomes for patients, 2) lower workload and more job satisfaction for healthcare providers, and 3) more efficient business operations and lowering of costs for managers in the healthcare sector. And the best thing is: it’s all within reach.

Focus on risks instead of diseases

The biggest pitfall of our current healthcare system is the disease instead of person-focus view. Nowadays we are dealing with an increasing group of people who have two or more diseases simultaneously, who risk falling between the cracks because of this focus when it comes to healthcare. It is much smarter to adapt healthcare and organize it on the basis of risks and the patient’s corresponding health needs. By identifying unique subgroups of patients, healthcare organizations can offer person-centered care instead of a single disease one-size-fits-all approach. That way, they have more influence on a better outcome for these patient groups. They can also organize their care more (cost) efficiently. This means that the traditional chronic disease divide of groups (e.g. diabetes type 2, COPD, heart failure, oncology etc.) will become less important in the near future. This is a new way of thinking, at least for the Netherlands. In other countries, like the US, Australia, New Zealand and Colombia, it’s already proven effective. Their best practices show us that realizing the right kind of care in the right place starts with dividing patients based on risk stratification models.

How does risk stratification work?

All healthcare providers need to register data in a database. Releasing risk stratification algorithms on the data in such a database is a relatively simple way to categorize patients on the basis of risk profiles. Some people struggle with the idea of using algorithms because of negative associations. This is a shame and unjustified, because algorithms are much better at tracking down patterns than the average healthcare providerwhichis incredibly beneficial to your organization. We will try to explain what it benefits exactly based on three risk profiles that can be detected by means of risk stratification. We start with a short description of the profiles and explain step by step how, as a healthcare provider/organization, you can use it to adapt your healthcare services to these profiles.

Image 1: How risk stratification works

High risk patients

This group, which accounts for approximately 5% of the population, consists of people that visit their GP or another healthcare provider more than twenty times a year for different reasons. The so-called superusers.Not unsurprisingly, we find a lot of vulnerable elderly people in this group. But also people who have mental health issues. The group is more heterogeneous than you would think. For example, risk analyses can show us that a lot of superusers are middle-aged women with families. A group you wouldn’t necessarily think of right away, but that can clog up your consultation hour in your daily practices just as much as other high-risk patients.

Step by step plan:

1. Link every high-risk patient to a case manager. This can be a nurse practitioner, a district nurse, a GP or a specialist in geriatrics. The case manager coordinates the care of a patient along the entire spectrum of prevention, care and wellbeing.

1. 2. It’s important for the case manager to get off on the right foot with a patient. For example by making an appointment to get to know each other and explaining his/her role.
3. 3. The case manager and the patient then create a custom healthcare plan. The standardized approach with set templates and documentation options within the electronic health record (EHR) can be used for this. The healthcare plan can include clinical and non-clinical problems. Self-care and shared decision making are always part of a healthcare plan.
5. 4. Since a high-risk patient almost always deals with health and social related issues, it’s important that this case manager has a wide range of social tools at his or her disposal and is good at cooperating.

Increased risk patients

This group consists of people with one or more chronic diseases who switch between stable and unstable periods. It’s good to take into account factors such as obesity, depression, high blood pressure, high cholesterol, high blood sugar (pre-diabetic) and tobacco consumption in risk stratification algorithms. The goal here should be that these people don’t move into the high-risk category.

Step by step plan:

1. 1. Have a care group or health center coordinate the healthcare and make sure all relevant disciplines are represented. Models like Accountable Care Organization, and Patient Centered Medical Home (PCMH) are examples that already use this method.
3. 2. Try to involve the patients in their care as much as possible. This can be done through self-help support, shared decision-making, written healthcare plans and patient surveys. Family and friends can also be involved as ‘influencers’. They can encourage the patient in their self-care and act as an extension of the healthcare team, for example by informing the healthcare team of any significant changes.
5. 3. Plan yearly preventative screenings for chronic conditions. This will make it easy to detect gaps in care and risks. These can be done by a health coach.
7. 4. Invite increased risk patients to try new types of care. Like eHealth applications, online forums, group sessions and health coaches. Research has shown it’s also smart to involve family and friends at this stage.

Low risk patients

This is the remaining group: people that are healthy or whose health is stable. The goal of this type of care is to keep these people healthy. This can be done cheaper, more efficiently and more goal-oriented than it is now.

Step by step plan:

1. 1. Develop an online patient portal for the initial communications and encourage low risk patients to use it (image 1). You can put information about for example the most common conditions and what to do if you have those. This stimulates self-management. Research has shown that this approach increases the patient’s engagement with the organization. This is interesting because it can encourage efficiency in use of care. The number of unnecessary consultation visits can be brought down this way.
3. 2. Focus on low risk interventions. As described above, it is important to manage the low risk patient population in an efficient way. Explore other strategies to engage with these groups even better and prevent them from becoming increased risk patients.
5. 3. Reserve time and capacity for (online) prevention and preventing unexpected healthcare needs. This doesn’t necessarily need to be done by a doctor, often times a nurse practitioner or doctor’s assistant can suffice.

Image 2: Online e-Health interventions

How is this beneficial?

Research has shown that risk stratification is the way to put value-based healthcare (VBHC and/or Triple Aim)into practice and actually generate better outcomes. It forms the basis of offering custom proactive care. Coordinated, patient-centered care saves the patient unnecessary treatments and time. The focus on prevention can also avoid a lot of unwanted outcomes. This all leads to higher patient satisfaction and better healthcare outcomes. This is also beneficial for healthcare providers. By organizing care based on risk groups, valuable time can be used in a more efficient way. Instead of scheduling ten minutes for every consultation, you distinguish between these risk groups. You give low risk groups less time and high-risk patients more, which means you have more time to properly help the latter and they will visit less during consultation hours. It also means a better division of labor. Not every patient needs to see a doctor for every problem. Some cases can actually be easily solved online. This decreases the workload and costs and increases job satisfaction. Risk stratification also means managers can make more specific contractual agreements with health insurers or governments. Right now, those agreements are based on volume and price, mostly based on nation-wide statistics. But it’s hard to determine a nationwide average. The need for care in a metropolitan area is completely different from the one in rural areas. If you can map how they differ, you can make agreements based on the regional situation. This increases the quality of care and saves costs.

So what’s stopping us?

That’s the main question, because it doesn’t seem to be taking off. There is still too much talking and too little action. Risk stratification is only possible if healthcare providers manage their data right and report the relevant data. That means no process indicators, but outcome indicators, like quality, health and cost (Triple Aim). It’s also important to link data systems. And don’t say it can’t be done because of privacy. That’s a fallacy. It’s undoubtedly possible to link data sets and adhere to privacy regulations. It’s not technique and regulations that are stopping us, but the prevailing culture. It’s almost like we’re afraid of the unknown. We need to be brave enough to move past that. Because we can influence that full waiting room as healthcare providers. We can negotiate better contracts. Let’s try to do that proactively. Instead of waiting until the government or health insurers take action when the situation becomes unsustainable, let’s take matters into our own hands and work on risk stratification. That way we stand up for ourselves and for our patients.

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