At Medical Home Network (MHN); working with our providers, we have found that effective care management is driven by combining two factors: 1) a comprehensive model of care that risk stratifies patients based on medical, social, and behavioral determinants using a predictive algorithm with continuous readjustment as new patient information is available, and 2) provider connectivity through a technology platform that combines real-time alerts in historical patient context and streamlines timely and actionable data flow across formerly hospitals and clinics.
This webinar will describe MHN’s dynamic and predictive risk stratification methodology using medical, social and behavioral determinants of health, which is crucial in the effort to improve care coordination, optimize daily workflows and point-of care decision making, and improve patient health through personalized care plans. Our risk stratification approach is proven to be predictive of subsequent total cost of care and hospital utilization. We will present both statistical analysis demonstrating the validity of the overall approach and the impact on these and other important measures that our risk stratification model can identify at a per-patient level. This level of analysis confirms that we can proactively address rising risk in a patient population.
- Learn some best practices for engaging patients to complete screening health risk assessments
- Appreciate the value of incorporating addressable barriers to treatment plan compliance that include social determinants of health to identify the rising risk population
- Understand the role of connectivity and analytics in an electronic care plan platform to improve care management outcomes.
Target Audience: Value Based Health Care Leaders, Population Health Teams, Integrated Delivery System and ACO Leaders, Physicians, CMO, CMIO, Care Management Leadership