311288
Disease-specific patient stratification model
Objective/Purpose: Patients often suffer from multiple indicators for each chronic condition and a comprehensive quality improvement effort to address the needs of vulnerable populations was being considered at NO/AIDS Task Force.
Methods: A weighted patient-stratification model for each chronic disease under consideration was developed using selected labs and vital sign values including selected user defined fields. Additional variables such as emergency department and in-patient admissions data from Greater New Orleans Health Information Exchange and stages of change assessment tool are being included. Registries created using business intelligence platform was used to identify patients. Then each patient appointment was color coded on provider schedules. High need patients in patient-stratification model are currently receiving electronic individualized multi-disciplinary care plans, which are embedded in Electronic Health Record (EHR). Each care plan is initiated by a nurse in consultation with a patient and then medical case management and behavioral health therapy follow.
Results: The viral load suppression increased from 76% in December of 2011 to 88% in April of 2013 and is 81% as of December, 2013. Number of patients with at least one HbA1c test increased from 88.5% to 94%. Patients with HbA1c more than 9% is decreased from 30.8% to 16%. Care plan administration compliance rate, average of each indicator at population level and adjusted prevalence are being studied.
Discussions/Conclusions: The project was facilitated by understanding data schema for EHR and ability to customize care plans in EHR among others. Very few research-based patient stratification models for primary care ambulatory sites allow each organization to individualize and test models of best fit. Next, the agency plans to develop effective predictive models for its population based on data collected.
Learning Areas:
Administration, management, leadershipChronic disease management and prevention
Epidemiology
Implementation of health education strategies, interventions and programs
Planning of health education strategies, interventions, and programs
Program planning
Learning Objectives:
Discuss models to stratify patient population
Formulate benefits of individualized multi-disciplinary care plans
Demonstrate value of data schema and patient registries
Assess patient satisfaction through standard methodologies
Keyword(s): Quality Improvement, Chronic Disease Management and Care
Qualified on the content I am responsible for because: Seema Gai is NO/AIDS Task Force's Chief Information Officer with over 10 years of experience in health care. She oversees execution of multiple quality management initiatives to build capability and redesign care delivery within the primary care practice. She leads a quality team focusing on cost control using national framework tools on population health management. She served as PI for this project demonstrating patient stratification model at a HIV ambulatory facility.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.