Using Point of Care Registries to Manage High-Risk Patients

Ten percent of patients account for more than 50 percent of medical costs, but creating a risk-stratified care management (RSCM) system that registers a variety of patient data can help patients achieve the best health and quality of life, according to Bruce Bagley, a physician and president and CEO of practice consulting firm TransforMED.

Bagley presented "Partnering with Patients in Care Management" at the 2014 Medical Group Management Association Annual Conference on Mon., Oct. 27.

Bagley suggested physicians identify a patient's health risk category on a scale from level 1 (low risk) to level 6 (highest risk and care) based on chronic conditions and risk factors such as smoking. Using RSCM, those with the highest risk should be entered into a point of care (POC) registry system, which detects those patients who need the most help managing their chronic conditions and navigating the often confusing medical system. In turn, this helps ensure evidence-based timely care and keeps medical costs in check.

Creating an Effective RSCM

The best tip Bagley provided in creating a RSCM is to keep it simple. Create a simple algorithm that anyone on the team can use to assign a risk score, but don't rely only on fixed algorithms. Clinical input from physicians who actually know patients can offer information beyond the numbers. Make sure there is a searchable field in the EHR so patients with specific risk factors can be pulled into the POC registry system to ensure coordination of care.

Even though those with higher risk scores, especially those at levels 5 and 6, will require more detailed care plans, the medical team should determine what is needed for each risk level and develop a checklist so that everyone has a care plan. The goal is to ensure everyone can take preventative measures (such as maintaining current vaccinations) and get the support needed so that risk levels do not elevate unnecessarily, Bagley said.

Use of POC Registries for High-Risk Patients

Those patients deemed to be a high risk based on the algorithm in the RSCM system should be entered into a POC registry, providing a physician's practice with a comprehensive overview of each individual's care coordination. It should comprehensively provide information such as current medications, last emergency room and hospital visits, and home care needs as well as notes on when the patient was last contacted and who provides caregiver support. "It really is a team effort," Bagley said, noting that physician care is only a part of the care and support high-risk patients need.

A POC registry also needs to provide easy-to-view information on what holes exist in a patient's care - for example, if someone lacks a recent eye examination - and everything reported needs to be important, relevant and up-to-date. "Rather than going to three different registries, the goal is to pull up one registry," Bagley said. "And it has to provide a snapshot of how that patient is doing at this point in time."

He noted that the registry needs to be monitored on a regular basis so that team members can touch base with high-risk patients when appropriate, including after hospital or emergency room visits. With a care plan in place, appropriate resources can be matched to each patient to meet specific needs, and care coordination can be put in place so that everyone involved in the patient's medical plan-including the primary-care physician, specialists, and home care and support specialists-knows exactly what the status is on that patient at any given time.

Though the POC provides a comprehensive view of a high-risk patient's situation in a snapshot moment, Bagley pointed out that it's important to note other special circumstances that could impact someone's care, such as cognitive impairment, poly-pharmacy issues, social isolation, mobility conditions and vision and hearing impairment.