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Improving Care for the Frailest Patients: How Two Value-Based Care Best Practices Can Help

Prior to the pandemic, practices relied on patients to outreach to their providers and make appointments for preventive care. This historical passive approach can leave a practice’s most frail patients unseen and undertreated because the individual may not reach out to their providers before they are in crisis.  Providers may only learn of the patient’s health challenges when they show up at the emergency room.

The benefits of proactive chronic condition management support everyone in the health care system, and with the growth of value-based care, it can now be realized. But effectively managing this process still has room for improvement.  As the volume of patients with chronic diseases grows, and the acuity of those patients intensifies, physicians must find straightforward ways to consistently identify their sickest patients and help them manage their care effectively. 

This is where value-based care provides an advantage  

With models that encourage proactive care management and offer greater flexibility, providers are better able to identify their frailest patients, target preventive care, and even get creative in breaking down possible barriers to that care. Two best practices are essential for this work. The first involves leveraging data intelligence solutions to find those patients who have multiple chronic conditions and who may be at risk for a negative health event. By using technology that sifts through claims data, electronic health record data and admit, discharge, transfer (ADT) data, providers can more effectively stratify their patient population, pinpointing those individuals at greatest risk. These tools can not only help providers understand the acuity of their patient population as a whole, but also identify patients who require more, or new, outreach and connection. Providers can then use the data to prioritize their time and resources, focusing on those patients who need the most care.  

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The second best practice involves coordinating the care for those high-risk patients identified through data intelligence. This involves targeted outreach and communication. Using the appropriate clinicians and staff, a practice can connect with patients and set up appointments for physicals and screenings, reconcile medications, and determine the need for specialist visits. Clinicians can also check in with patients who have recently been discharged from the hospital to ensure they are following treatment plans and have what they need to avoid readmission. One of the most helpful tasks a clinician can handle is finding out if there is anything preventing a patient from complying with a treatment plan, attending an appointment or filling a prescription. If there are barriers, such as transportation issues, lack of access to healthy meals, health literacy concerns or economic challenges, clinicians and staff can work with the patient and family to find solutions. Value-based care models support the idea of providers building relationships with community partners and identifying other resources that can alleviate any obstacles standing in the way of good care. 

A partner focused on clinical value is key

Strong data intelligence coupled with proactive outreach can make a significant difference in the lives of patients. However, these strategies require dedicated resources that may be hard to come by if an organization operates alone. Relying on an expert partner to deploy strategies and solutions can enable more targeted outreach and support better operational processes. This helps providers care for patients when and how they need it–helping the physician get back to the reasons why they entered primary care medicine in the first place. 

Rob Cetti
President at

Rob Cetti is the President of CareAllies, a company that collaborates with independent physicians to accelerate their transition to value-based care. There, Cetti focuses on further connecting care between patients and providers through innovative value-based care solutions that help reduce health care costs, while improving quality and overall care experiences. Cetti has served in a variety of leadership roles during his cumulative 20 years with CareAllies and Cigna. He most recently led Cigna's affordability efforts for U.S. Commercial and Medicare Advantage in Arizona, focusing on provider contracting in the market, including for Medicare and accountable care organizations in alternative payment models.

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