Risk stratification is essential for complex care programs to identify patients with high or rising risk and to tailor programs accordingly. However, many programs only have access to clinical indicators of risk and aren’t able to incorporate social determinants of health or other sources of data when risk stratifying patients.
The Sooner Health Access Network (HAN) is a Medicaid-academic collaboration that provides a range of care management services for Medicaid beneficiaries in Patient-Centered Medical Homes across the state of Oklahoma. In serving this population, HAN has developed a process to stratify patients using a wide array of data sources, including social needs.
From the Sooner Health Access Network, Rachel Mix, Director, Glenda Armstrong, Care Management Clinical Manager, Kristin Steuck, Care Management Operations Manager, and Chelsea Bishop, Quality Manager will discuss how they have implemented this process in different practice settings and how providers can take the next steps once the patients are identified.
- How can providers best leverage available data to incorporate social needs (e.g. claims data, real-time hospital admission, discharge, and transfer data)?
- Are certain social determinants of health more indicative of high or rising risk than others?
- Once patients are stratified by risk, what are the next steps to best tailor programs accordingly?
- Rachel Mix, Director, Sooner Health Access Network
- Glenda Armstrong, Care Management Clinical Manager, Sooner Health Access Network
- Kristin Steuck, Care Management Operations Manager, Sooner Health Access Network
- Chelsea Bishop, Quality Manager, Sooner Health Access Network
What are Office Hours for Complex Care?
Beginning in January 2018, the National Center for Complex Health and Social Needs will host monthly Office Hours for Complex Care as an opportunity for engagement with subject matter experts across the country. Free of charge and hosted through the teleconferencing platform Zoom, Office Hours will feature hour-long Q&A sessions designed to connect National Center members with experts in relevant areas. Topics will vary from month-to-month and will cover a range of subjects that relate to the field of complex care. Feel free to join as a group and be sure to bring your questions for the session hosts and other participants!