Advanced Analytics & Research
A patient centric environment requires harmonious relations between the patient and the health care providers. Working through patient advocacy groups is an efficient way for pharma to interact with patients to get their opinions, feedback and also increase their involvement in the trials and treatment processes. In situations where access to medicine is denied these advocacy groups can move from the role of support to an adversarial role.
Risk stratification (Risk scoring):
Risk stratification enables providers to identify the right level of care and services for distinct subgroups of patients. It is the process of assigning a risk status to a patient and then using this information to direct care and improve overall health outcomes.
Top performing population health-focused organizations practice risk stratification. Population health management requires practices to consider patients as both individuals and as members of a population. At the individual level, a patient’s risk category is the first step towards planning, developing and implementing a personalized patient care plan. Typically, patients are segmented into high-, medium- (rising-) and low-risk groups. At the population level, risk stratification allows care models to be personalized to the needs of patients within each subgroup.
The goal of risk stratification is to segment patients into distinct groups of similar complexity and care needs. For health centers, these groupings can include: highly complex, high-risk, rising-risk, and low-risk individuals. Unique care models and intervention strategies are then used for each group:
This service is particularly helpful in identifying a cohort of high risk individuals who can benefit from one-on-one care management. The exercise of stratifying by condition counts, particularly as related to identifying patients eligible for care management, can be supplemented by provider and care team referrals. The care team best knows patients who, for example, fall outside the ‘high risk’ group but are most in need of care management support.
AKT Health offers various reports in support of Risk Stratification including:
- A monthly updated list to General Practice of people at risk of an unscheduled hospital admission. This list is presented through the familiar tiered pyramid. GP’s can drill down into these cohorts of patients and filter by various headings:
- Risk score
- Hospital utilisation costs
- Number of admissions
- Number of Long Term Conditions
- Number of medication items High Climbers Report to identify those patients that are rapidly moving up the pyramid
- Re-admission reporting to identify ‘revolving door’ patients
- Cost Profiling: This is an incredibly powerful screen that allows the analysis of costs of patients in terms of hospital care over a chosen time period. Filtering between Long Term Conditions and by type of episode is also available.
AKT health has an identical approach to risk stratification and offers a solution that covers all fields of the QIPP long term conditions work stream. AKT health encourages Commissioners and general practice to adopt a more holistic approach, rather than just focusing on “Risk Profiling”.
Our Risk Stratification & Case Finding module offers an end-to-end solution that will support Commissioners and General Practice in:
- Risk Stratification
- Case Finding for Integrated Care Teams
- Systematizing Self Care (Care Planning)
Key areas of our approach in risk stratification:
Historical patient data is used to build a model that predicts future healthcare events or outcomes for individuals (Combined Predictive Model)
Customer defined inclusion criteria to identify patients and refer patients to a specific healthcare intervention
Patients are identified for clinical review to confirm their appropriateness for a specific healthcare intervention.
Health Intelligence partners with various academic institutes to offer a service where we can track patients throughout an intervention. This will allow commissioners to evaluate providers in regards to both financial and clinical outcomes.
Integrated across all health care sectors, this supports the development of shared actions and goals, engaging patients to take a more active self-care role in maintaining or improving their own health
Another sort of prescient methodology AKT Health utilizes with its accomplices is simulation (what-if scenarios), which are important when decision makers need to ask basic “consider the possibility that” inquiries regarding a given clinical territory or authoritative capacity.
More clinically targeted example from the advanced analytics application for the cutting out population module feature a length-of-stay simulation, that demonstrates the monetary impact (dollars saved) and improved patient satisfaction of shorter patient stays within the hospital. Predictive analytics utilized in a simulation setting provides clinicians and directors a glimpse into “what-if” situations and therefore the possible outcomes of a given combination of events.
Geographic information systems (GIS) and geo-spatial analysis could be a well-developed business, having passed its 50th day of remembrance mark. Despite those 5 decades, the apparent overlap to investing GIS tools with healthcare and geomedicine is simply currently coming back into focus. Solely recently have massive sets of national claims and payment information been created public. To boot, non-public and non-profit institutions have massive amounts of operational and patient knowledge that would be mapped.
Mapping layers and predictive analytics are habitually accustomed forecast weather, optimize supply chains, and support military preparation. A natural extension of those established approaches is to leverage GIS mapping of healthcare facilities, patient illness burden, and responsible care populations. Mapping is a good visual approach to analytics and higher cognitive process.