Managing High Risk Populations, a System-wide Approach to Complex Care Management

About the Program

Category: Health (Best in Category)

Year: 2019

Los Angeles County implemented HealtheIntent, a population management system, known within the Los Angeles County Department of Health Services (DHS) as Empanelment Life Management (ELM) Care Management that leverages data from the Electronic Health Record and Registries to identify a subpopulation of high-risk patients for the Patient Centered Medical Home (PCMH) Care Managers to follow. Prior to launching ELM Care Management, no automated methodology was available to find patients that met defined high-risk criteria. Care Managers were missing opportunities to intervene and support complex patients. DHS is the second largest safety-net system in the country. Many patients have multiple chronic conditions, and remain uninsured or underinsured. Social problems compound the impact of disease in this population. Care managers assigned to work in the PCMH clinics care for approximately 300,000 empaneled patients.The ELM Care Management Solution was implemented November 2017 and proved successful in assisting with timely identification of high-risk patients. Care management intervention was associated with• Decreased Inpatient utilization (30 inpatient visits per 1,000 cases).• Decreased Observation utilization (5 observation visits per 1,000 cases).• Decreased Emergency utilization (30 emergency visits per 1,000 cases).• Increased Outpatient utilization (220 visits per 1,000 cases).