Play: Identify Patients with Quantitative and Qualitative Criteria

Play Strategy

Once you’ve selected your population of focus, what is your process for identifying and enrolling patients who meet your criteria for inclusion in the enhanced care program? One approach is to use multiple sources of information to validate which patients are included. For example, Cambridge Health Alliance (CHA), an Accountable Care Organization (ACO) and safety-net health system in Cambridge, Mass., uses a triage tool and a bi-directional validation process to enroll patients in an enhanced care program. This process incorporates health care utilization data, primary care provider expertise, and a quantitative score to identify patients for inclusion.

The goal of this play is to help you choose patients to include in your program, once you’ve identified your population segment and criteria for inclusion.

Play: Identify Patients with Qualitative and Quantitative Criteria
How to run the Play
  1. Identify criteria to include patients in the care management program, based on the population segment you want to enroll.
  2. Identify patients who meet the criteria from health care utilization data such as hospital records of emergency department visits and insurance claims data.
  3. Work with clinical teams to review data-driven referrals and validate patients for inclusion based on their experience. For example, here are some questions providers might answer:  
    • Would you be surprised if this patient is hospitalized or has an ED visit in the next six months?
    • Would you be surprised if this patient died in the next year?
    • Will this patient engage with a care manager?
    • What is the focal area for a care management intervention?
  4. Enroll patients in the program, and follow their progress to refine your criteria for inclusion.
Tips and tricks
  • Use feedback from primary care providers to refine the data-driven criteria you’ve selected.
  • To enroll patients on an ongoing basis, set up a process to alert primary care providers when one of their patients presents in the ED or is admitted to the hospital, so that the provider can consider them for enrollment in the enhanced care plan.
  • Consider using a quantitative tool, such as the CHA Triage Tool (see below), to serve as a last check on which patients to include.
  • Consider how you will monitor and evaluate the success of your selection criteria, and revisit the process at regular intervals to adjust the criteria for inclusion based on what you learn. You may follow patients who were not selected for inclusion, as well as those who were, to learn about the effectiveness of your criteria.
 
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