Predicting levels of high risk: Minnesota health plan decreases hospital admission rates for high-risk members - Disease management: case history

Health Management Technology, April, 2003 by Karen K. Kraemer

One of the central questions in disease management (DM) today is whether it should address entire populations or target just those individuals at greatest health risk. HealthPartners, a nonprofit health plan that serves 680,000 members in Minnesota, has found it can do both by employing a population health model based on the distribution of all members by risk level from healthy/low risk to active disease (Figure 1). Health-Partners formulates and implements an array of programs and tactics aimed precisely at discrete segments of the membership population at different stages along the risk continuum.

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Our outpatient case management program is responsible for members with early symptoms and active disease. Within our overall DM program structure, Partners for Better Health (PBH), our focus is on those members at the highest levels of health risk. Accurately predicting members' health risk is essential to success. HealthPartners uses the CareLink system from StatusOne Health Systems, Westboro, MA, to guide and manage the process, and has achieved a solid return on investment with the system.

Predicting High Risk

Our case management department includes 63 registered nurses with a combined total of 1,351 years of clinical practice and case management experience. Outpatient case managers identify and manage complex, high-risk members who have active disease and are presumed to be at greatest risk for complications and hospitalization.

We needed a practical and effective system to pinpoint these members, and in October 2001, we selected CareLink. In evaluating alternatives, we found CareLink to be comprehensive and sophisticated. We were impressed with the documented accuracy of its methodology for identifying and stratifying high-risk members. Our nurse case managers also concluded that the system was congruent with processes already in place and that it would be easy to learn and deploy. Since it is implemented on the ASP model and accessed over the Internet, it required minimal internal IT resources for installation and maintenance.

Other vendors HealthPartners evaluated were still in the R&D stage and wanted to partner with us to develop a solution, but we wanted a complete, proven system that we could put in place quickly. We determined that with StatusOne, we could achieve measurable progress within a year, and they were willing to bear financial risk for our results.

At the start of the contract, HealthPartners prepared and transmitted encrypted files with a complete claims history for all members. It included data fields for patient demographics as well as diagnosis and procedure codes. StatusOne processed the data through a series of proprietary algorithms that identify patterns pinpointing potential deteriorating conditions, complications and high costs of care. The result was a registry of potentially high-risk members that included approximately 0.5 percent of HealthPartners' population, about 3,350 members.

Once the initial registry was established in January 2002, HealthPartners began sending monthly supplemental claims input. Within two weeks, updated registries were available online, and monthly updates identified new, potentially high-risk members. HealthPartners also has the option to add individuals referred by physicians, case managers, home care providers or members themselves.

The registry and associated data are available to HealthPartners' outpatient case managers online via an ASP model. StatusOne trained all case managers on the use of the system.

HealthPartners' outpatient case management nurses call each member on the registry. Using specialized training on motivational interviewing, they engage and assess the members and assign them to a StatusOne acuity level, from likely to be hospitalized within the next three months to beyond two years (Figure 2).

Nurse case managers rely on their clinical experience, critical thinking skills and training to assign acuity levels based on the patient's utilization history, the health screening they conduct with the patient, and their analysis of the current clinical and social situation of the patient. Case managers also ask members to rate their own general health and functional status from "1" (poor) to "5" (excellent). They initiate interventions and calibrate the frequency of member contacts and reassessments based on these acuity and functional status levels.

Managing Risk

Each month, about 2,500 highrisk members are in active outpatient case management. The CareLink system provides the working tools for designing and implementing care plans, including software tools to track action plans, enter input from consults and access resources. The application also includes outcomes metrics that encompass both process measures and utilization outcomes, available at several levels of summarization.

Nurse case managers use the system to formulate a health action plan with each high-risk member. The plan summarizes particular goals that the individual member believes are most important and to which he or she is committed. The nurses inform primary care physicians when one of their members is enrolled in case management, discuss physicians' views and plans for care, and then share significant findings from their conversations with and assessments of patients.