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An Approach to Care Management for High-Risk Patients

An Approach to Care Management for High-Risk Patients

Increasingly, Medicare payments are tied to the value and quality of services provided, which means that as physicians we must consider new approaches to caring for patients who are most at risk. It sounds great in theory, but how does it affect the way we actually care for Medicare patients?

When your practice assumes the care of a Medicare population under a value-based agreement, it can be a challenging endeavor. The Medicare population is expanding rapidly and some enrolled in Medicare will require a highly personalized level of care. Here is a five-step approach to assist primary-care physicians as they develop strategies to best manage their population of Medicare patients in value-based arrangements.

Step 1: Identify fragile and high-risk patients

A 2012 CMS survey found that more than two-thirds of Medicare recipients had at least two or more chronic conditions. But there are several warning signs that can help you evaluate who the most fragile and high-risk patients are. If you do not have access to predictive models for your patient panel, here are some factors which can help you identify which patients are at high risk:

• Managing multiple comorbidities

• Patients who have limited ability to perform IADLs

• Prior hospitalization in the last year

• Frequent ER visits within the past six months

• Behavioral health conditions

• Poor social support or financial barriers to health access

• Noncompliant/unable to contact

Step 2: Focus on removing barriers to accessing care

Providing easy access to care is key to managing high-risk patients and keeping them out of the emergency department. The following steps can help:

• Schedule well-office visits to proactively address chronic conditions

• Provide adequate number of same-day appointment slots to address acute conditions

• If possible, provide extended office hours

• Educate the patient and caregivers on disease-specific warning signs

• Simplify the medication schedule and perform regular medication reconciliation

• Refer to specialists who can see patients promptly and will consistently communicate their findings back to you


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