Augmenting Predictive Modeling Tools with Clinical Insights for Care Coordination Program Design and Implementation.

Area of Science:

• Health Services Research
• Health Informatics
• Population Health Management

Background:

• Denver Health (DH) received $19.8 million from the Center for Medicare and Medicaid Innovation (CMMI) to implement a population health strategy in primary care.
• This initiative builds upon the Patient Centered Medical Home (PCMH) and Wagner's Chronic Care Model (CCM).
• The goal is to achieve the Triple Aim: enhancing population health, individual care, and reducing per capita costs.

Purpose of the Study:

• To present a case study of DH's integration of predictive models and clinical judgment for patient risk stratification.
• To describe the development and implementation of a Health Information Technology (HIT) solution for clinically actionable patient risk stratification.
• To demonstrate how population segmentation can optimize care management and resource allocation.

Main Methods:

• Integrated published predictive models with front-line clinical judgment to stratify patients.
• Utilized population segmentation to deploy enhanced care team resources and tailor services.
• Developed and refined a Health Information Technology (HIT) solution for patient risk stratification.
• Employed dynamic business intelligence tools for real-time data visualization and decision-making.

Main Results:

• The IT solution facilitated multidisciplinary development and iterative refinement.
• Key processes included team composition, population definition, algorithm development, performance assessment, and workflow optimization.
• Business intelligence tools provided accessible, real-time data views from population to patient levels.

Conclusions:

• Population segmentation, integrating clinical insights with predictive modeling, effectively identifies high-risk patients.
• This approach supports targeted, enhanced care team interventions within a medical home setting.
• The study highlights the importance of leadership and organizational processes in successful practice transformation.