Risk Stratification–Critical for Effective Care Management
Success in population health is dependent upon an organizations’ ability to use data and analytics to identify patients who could benefit the most from services. Using the EDW, Partners HealthCare is developing a patient identification algorithm that combines claims, clinical, and social information. Primary care clinicians review their list of algorithm-identified patients to select those who would benefit most from the Integrated Care Management Program.
Improved data availability supports identification of younger commercial and Medicaid populations.
Hybrid patient identification approach minimizes unintentional variation and biases while ensuring PCP buy-in.
Continuous improvement of algorithm to maximize use of data available in the EDW.