Creating a Coherent View: Evolent Health says organizations must integrate multiple sources of information, provide real-time alerts for ED admissions, and be able to transmit care manager notes to the appropriate providers
Prioritizing High-Risk Patients: Williams noted that organizations could model their programs off the success of a UPMC team who has been assessing patients for years by collecting data and processing it through a rules engine to create predictive models for readmission risks and risk scores.
Providing the Right Intervention by Building a Targeted and Tiered Intervention Portfolio: Evolent Health stratifies patients into buckets and creates a menu of interventions and care management operations to address particular patients. One key is to corral a team of R.N.s, social workers, and health coaches to create patient-centric workflows and prioritized outreach.
Engaging at the Appropriate Intensity Level: three levels of patient outreach.
-Routine care gaps can be addressed by social media, email, or conceierge ourtreach and scheduling.
-Medium intensity patients can be targeted with health coaches, social workers, nutritionists, pharmacy outreach, etc.
-High Intesity patients can be engaged by specialist care managers, home monitoring devices, chronic care clinics, or complex case management methods.