Identifying High-Risk Patients

Identifying high-risk patients is a key to many care management and wellness programs.  Claims data is often used as a source for this identification, as is biometric information.  Research published in the journal Health Services Review suggests use of some additional data that attempts to measure the level of patient engagement health.   (HSR Article)   This work builds on the “Patient Activation Measure” created by Judith Hibbard and colleagues.  This measure supposedly shows that level of engagement is correlated with lower health costs and better quality outcomes.  Data used in the study was extracted from the EHR of a large accountable care organization with around 100,000 patients.  Patients’ PAM scores were calculated for 2011 and care utilization for 2012-14 was examined, particularly for ambulatory care-sensitive conditions, meaning those where good primary care might have avoided ER use or hospitalizations.  Persons with low PAM scores were those who said they did not feel competent to navigate the health system on their own or to manage their own health.  These patients were 25% more likely than consumers with the highest PAM scores to develop a chronic disease during the study period and also had higher rates of hospitalization, 62% more likely to have one,  and emergency room use for ambulatory-care sensitive conditions.  This suggests that adding this survey-type data on activation level, or really health and health care management competence, can be a useful factor in stratifying patients by risk of high service utilization.  Identifying these patients may also help direct resources toward aiding them with health care decisions and activities.  Of course, the PAM level probably is strongly linked to patients’ health status by its nature, since people in poor health tend to have less cognitive and physical energy to deal with health care decisions and to be more despondent about their skills in general.