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An Approach to Care Management for High-Risk Patients


As compensation becomes more closely tied to value-based care, it behooves physicians to develop new strategies to care for their sickest 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

Step 3: Engage the patient in an action plan for changes to a condition

To help prevent future hospitalizations, ER visits, and other health complications, it's important to educate the patient and any caregivers so they can identify the signs of an emergency or decline in health. Arming patients with this knowledge helps them take charge of their own wellness. During appointments, consider discussing the following topics with both patients and caregivers, and offer them educational materials for in-home use to reinforce the information regarding:

  • How to make same-day appointments
  • Where to go for after-hours urgent care
  • How to tell the warning signs of heart attack, stroke, and other serious conditions for which they may be at risk
  • When to call for help and whom to call
  • Which hospital you prefer to use when time permits a choice of facility
  • When to use emergency care

Step 4: Connect with medical and social support services

Some proportion of your Medicare population will need services outside the scope of traditional primary care to help them and their caregivers properly manage specific health conditions. To coordinate holistic care for elderly or fragile patients your practice may need to engage outside services to:

  • Ensure that patients with complex medical conditions consult periodically with specialists
  • Refer to case management services when medically indicated
  • Refer to home health services as needed
  • Make referrals to local social services
  • Discuss palliative care options and advance directives with patients who have limited life expectancy
  • Engage the patient's caregiver in these discussions and care plans

Step 5: Perform after-hospital care

Hospital readmissions are unpleasant for your patients, are expensive, and may place your patients at increased risk for morbidity. Many hospital readmissions can be avoided if you:

  • Use census information to be sure you know which patients in your panel are in a hospital or skilled nursing facility
  • Communicate promptly with a hospitalist or attending physician, ideally verbally, at the time of discharge
  • Request a discharge care plan and summary
  • Schedule post-hospital visits with primary-care physician within 72 hours of discharge
  • Reconcile medication
  • Educate the patient on preventive measures for the future
  • Engage caregivers and family members in after-care instructions

Providing high-quality care to fragile Medicare members requires an entire ecosystem of health professionals. The best care we can give them is holistic and patient-centered care rather than costly and episodic. The primary-care physician plays a crucial role as the center of this ecosystem, advocating for the patient's health and coordinating all of the right resources to get them the care they need.

About the Author

Robert Grossman, MD, MBA, chief medical officer at Transcend, is a board-certified physician in internal and critical care medicine. Dr. Grossman obtained his medical degree from New York Medical College, his master's degree in business administration from the University of North Carolina, and his Bachelor of Science degreein psychology from Hamilton College. He can be reached at rgrossman@transcendphm.com

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