A panel of healthcare leaders discussed five key strategies organizations can use to manage the health of vulnerable patient populations during a session yesterday at the sixth annual National Accountable Care Organization (ACO) Summit in the District of Columbia.
Panel moderator Larry Atkins, Ph.D., executive director of the Long-Term Quality Alliance, said approximately 5 percent of an ACO's patient population are considered the most vulnerable, yet this group accounts for about half of its healthcare spending. Of these patients, Atkins said, 40 percent are seniors and 40 percent are younger adults with disabilities. Ninety percent of the vulnerable population has a chronic condition, and 60 percent has some kind of functional limitation, such as dementia or a developmental disability.
D. Clay Ackerly, M.D., chief clinical officer at naviHealth, Inc. suggested organizations use five strategies to manage these vulnerable patients' health:
- Understand their needs
- Partner/network with other community resources
- Match needs to services
- Execute safe transitions
- Determine post-discharge steps for care
Healthcare leaders must also understand that those patients' functional status (that is, how well they function physically, emotionally or cognitively) is a more accurate outcomes predictor than medical diagnoses, Ackerly said, and that means clinicians must actively engage them.
Similarly, Eliza Shulman, chief innovation engineer at Atrius Health in Boston, described her organization's long history of categorizing vulnerable patients by illness or condition. However, she said, when Atrius formed its own ACO, it saw an opportunity to "fundamentally restructure our care program" by looking at the specific factors that made patients high-risk, which often meant looking at functional status rather than illness.
One of the most important aspects for ACOs and providers to understand is that every major step toward improving outcomes for vulnerable populations means making a specific investment, according to Christine Ritchie, M.D., Harris Fishbon Distinguished Professor at the University of California San Francisco's (UCSF) department of medicine. For example, she said, to achieve coordination across settings, ACOs must invest in communication tools. To commit to an interprofessional model of care planning, the organizations must invest in team members who generate less revenue.
UCSF's Office of Population Health, Ritchie said, has established a tiered system of patient support that covers a spectrum of patients, organized by risk:
- Level 1 patients, the lowest vulnerability level, work with traditional primary care providers
- Level 2 patients, who have a moderate risk level, work with five healthcare navigators, who assist them in self-managing chronic conditions
- High-risk Level 3 patients work with the second tier of care support, which includes nurse practitioners, social workers and clinical pharmacists
Not only have these strategies significantly improved lengths of stay and emergency department visits, patients assessed their own health much more positively as well, according to Ritchie.