Integration of risk, quality and care programs
The primary focus of risk adjustment programs is to accurately access, document and report the chronic and acute health conditions of each member in the population. Often risk programs are organized within the financial department of a plan and the quality programs report to the clinical side.
Risk and quality programs work best when integrated within the organization. The risk program will identify members who fall into “high risk” groups and require additional screens and care to ensure that their health conditions do not progress or worsen. The quality program ensures that timely and complete care is provided and documented.
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The primary focus of risk adjustment programs is to accurately
access, document and report the chronic and acute health
conditions of each member in the population
The benefits of such an integrated program include 1) reduction of program administration costs by reducing duplication, and 2) prioritization of interventions that impact both risk and quality results. What’s more, population health moves from a single lens to a more holistic approach, improving the overall care and lowering the cost of supporting a population.
Deploying a holistic technology platform
Many organizations look at risk and quality as projects that are initiated and completed throughout the year. Technology and processes are scheduled and operate on a project cadence. This approach, however, leads to missed opportunities, because the population is always in flux. Once a member is identified for an intervention, there may be other factors that should have been reviewed or a test ordered. At the same time, a project approach limits the timeliness of data at the point of service and allows care and data to fall through the cracks.
Integration of risk, quality, and care programs removes silos between risk and quality programs to gain an efficient and integrated view of the population and outcomes
The alternative approach allows a plan to partner with the provider network and move to a program approach rather than a project approach. A program continually takes in new data requiring tighter data integration between the health plan’s systems and the provider Electronic Medical Record systems. Fresh data is used to stratify the population, identify gaps in risk, improve care quality, and provide actionable information to providers and members when they need it — at the point of care.
Integrated risk and quality programs proactively rely on fresh data to stratify the population, identify gaps in risk, improve care and provide actionable information that can be used at the point of care
The benefits of a holistic technology platform include the ability to deliver actionable information to the people who need it, when they need it. The care team can verify that the care that should be provided is, in fact, on track. Issues can be quickly identified and remedied before they cause significant consequences.
