New arrows in the quiver for targeting care management: High-risk versus high-opportunity case identification

Journal of Ambulatory Care Management

Volumn 30, Issue 1, 2007, Pages 39-51

  Bernstein, Richard H ^a,b  

^a MOUNT SINAI SCHOOL OF MEDICINE   (United States)

^b CareAdvantage Inc   (United States)

Author keywords

Case management; Disease management; Disease progression; Patient care management; Risk adjustment; Risk assessment; Risk factors; Severity of illness index; Statistical model; Utilization

Indexed keywords

CASE MANAGEMENT; DATA ANALYSIS; DISEASE SEVERITY; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HIGH RISK PATIENT; MODEL; OUTCOME ASSESSMENT; PATIENT CARE; PATIENT COMPLIANCE; PATIENT REFERRAL; PREDICTION; QUESTIONNAIRE; REVIEW; RISK ASSESSMENT; SCREENING;

EID: 33845747208     PISSN: 01489917     EISSN: None     Source Type: Journal    
DOI: 10.1097/00004479-200701000-00007     Document Type: Review

References (47)

1. Ash, A. S., Zhao, Y., Ellis, R. P., & Shlein Kramer, M. (2001, December). Finding future high-cost cases: Comparing prior cost versus diagnosis-based methods. Health Services Research, 36(6 pt 2), 194-206.
2. Balkrishnan, R. (2005). The importance of medication adherence in improving chronic-disease related outcomes: What we know and what we need to further know. Medical Care, 43, 517-520.
3. Berlinguet, M. (2002). Comparing the value of 3 diagnostic based risk adjustment systems [Slide presentation]. Funded by Fonds de Recherche en Santé du Québec and the Canadian Health Services Research Foundation.
4. Bodenheimer, T., Wagner E. H., & Brumbach, K. (2002). Improving primary care for patients with chronic illness. The Journal of the American Medical Association, 288, 1775-1779.
5. Boult, C., Pualwan, T. F., Fox, P. D., & Pacala, J. T. (1998). Identification and assessment of high-risk seniors. HMO Workgroup on Care Management. The American Journal of Managed Care, 4, 1137-1146.
6. Calhoun, J., Admire, K., & Casey, P. (2005). Implementing a predictive modeling program; part 1. Lippincotts Case Management, 10(4), 185-189.
7. Chen, A., Brown, R., Archibald, N., Aliotta, S., & Fox, P. D. (2000). Best practices in coordinated care. Retrieved July 27, 2006, from http://www.mathematicampr.com/PDFs/bestpractices.pdf
8. Choo, P. W., Rand, C. S., Inui, T. S., Lee, M.-L. T., Canning, C., & Platt, R. (2001). Derivation of adherence metrics from electronic dosing records. Journal of Clinical Epidemiology, 54, 619-626.
9. Coleman, E. A., Wagner, E. H., Grothaus, L. C., Hecht, J., Savarino, J., & Buchner, D. M. (1998, April). Predicting hospitalization and functional decline in older health plan enrollees: Are administrative data as accurate as self-report? Journal of the American Geriatrics Society, 46(4), 419-425.
10. Cousins, M. S., Shickle, L. M., & Bander, J. A. (2002). An introduction to predictive modeling for disease management risk stratification. Disease Management, 5(3), 157-167.
11. Crawford, A. G., Fuhr, J. P., Jr., Clarke, J., & Hubbs, B. (2005, October). Comparative effectiveness of total population versus disease-specific neural network models in predicting medical costs. Disease Management, 8(5), 277-287.
12. Cumming, R. B., Knutson, D., Cameron, B. A., & Derrick, B. (2002). A comparative analysis of claims-based methods of health risk assessment for commercial populations. Retrieved July 27, 2006, from http://www.soa.org/ccm/ cms-service/stream/asset?asset_id=9215098&g11n
13. Dang, D. K., Pont, J. M., & Portnoy, M. A. (1996a, March). Episode treatment groups: An illness classification and episode building system - Part I. Medical Interface, 9(3), 118-122.
14. Dang, D. K., Pont, J. M., & Portnoy, M. A. (1996b, April). Episode treatment groups: An illness classification and episode building system - Part II. Medical Interface, 9(4), 122-128.
15. Dorr, D. A., Wilcox, A., Burns, L., Brunker, C. P., Narus, S. P., & Clayton, P. D. (2006, Febuary). Implementing a multidisease chronic care model in primary care using people and technology. Disease Management, 9(1), 1-15.
16. Dove, H. G., Duncan, I., & Robb, A. (2003). A prediction model for targeting low-cost, high-risk members of managed care organizations. The American Journal of Managed Care, 9, 381-389.
17. Eggert, G. M., & Friedman, B. (1988). The need for special interventions for multiple hospital admission patients. Health Care Financing Review, Annual Supplement, 57-67.
18. Ferguson, J. A., & Weinberger, M. (1998). Case management programs in primary care. Journal of General Internal Medicine, 13, 123-126.
19. Fetterolf, D., Wennverg, D., & Devries, A. (2004). Estimating the return on investment in disease management programs using a pre-post analysis. Disease Management, 7(1), 5-23.
20. Goldfield, N., Averill, R., Eisenhandler, J., Hughes, J. S., Muldoon, J., Steinbeck, B. (1999, April). The prospective risk adjustment system. The Journal of Ambulatory Care Management, 22(2), 41-52.
21. Hanley, J. A., & McNeil, B. J. (1982, April). The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 143, 29-36.
22. Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39, 1005-1026.
23. Hu, G., & Root, M. (2005). Accuracy of prediction models in the context of disease management. Disease Management, 8, 42-47.
24. Hughes, J. S., Averill, R. F., Eisenhandler, J., Goldfield, N. I., Muldoon, J., & Neff, J. M. (2004, January). Clinical risk groups (CRGs): A classification system for risk-adjusted capitation-based payment and health care management. Medical Care, 42(1), 81-90.
25. Lorig, K. R., Sobel, D. S., Ritter, P. L., Laurent, D., & Hobbs, M. (2001). Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4, 256-262.
26. Lynch, J. P., Forman, S. A., Graff, S., & Gunby, M. C. (2000). High-risk population health management-achieving improved patient outcomes and near-term financial results. American Journal of Management Care, 6, 781-791.
27. Meek, J. A. (2003a, July/August). Predictive modeling and proactive care management; part 1. Lippincotts Case Management, 8(4), 170-174.
28. Meek, J. A. (2003b, September/October). Increasing return on investment potential in care management: Predictive modeling and proactive care management; part II. Lippincotts Case Management, 8(5), 198-202.
29. Mullahy, C. M. (2003). Case management and managed care. In P. R. Kongstvedt (Ed.), Essentials of managed health care (4th ed., chap. 13, pp. 249-28.). Gaithersburg, MD: Aspen.
30. Nash, D. B. (1998, Febuary). A clarion call for case managers. Journal of General Internal Medicine, 13(2), 144-145.
31. National Chronic Care Consortium. (1995). In brief: The elements of integrated care management. Retrieved August 18, 2006, from http://www. nccconline.org/products/N10095.pdf
32. National Chronic Care Consortium. (1997). Exploring risk identification as a process that supports the care management goals of the MSHO project. Retrieved August 18, 2006, from http://www.nccconline.org/products/M13697.pdf
33. National Chronic Care Consortium. (2000). Case management: methods and issues. Retrieved August 18, 2006, from http://www.nccconline.org/pdf/ CaseManagement.pdf
34. O'Connell, J. M., & Kauffman, L. D. (2002). A framework for disease management ROI studies: A healthplan perspective. Disease Management, 5(2), 109-121.
35. Pacala, J. T., Boult, C., Reed, R. L., & Aliberti, E. (1997, May). Predictive validity of the Pra instrument among older recipients of managed care. Journal of the American Geriatrics Society, 45(5), 614-617.
36. Plocher, D. W. (2003). Fundamental and core competencies. In P. R. Kongstvedt (Ed.), Essentials of managed health care (4th ed., chap. 14, pp. 281-292). Gaithersburg, MD: Aspen.
37. Radcliff, T. A., Cote, M. J., & Duncan, R. P. (2005, Summer). The identification of high-cost patients. Hospital Topics, 83(3), 17-24.
38. Retchin, S. M., & Ballard, D. J. (1998). Commentary: Establishing standards for the utility of administrative claims data. Health Services Research, 32, 861-866.
39. Rosenzweig, J. L., Weinger, K., Poirier-Solomon, L., & Rushton, M. (2002, November). Use of a disease severity index for evaluation of healthcare costs and management of comorbidities of patients with diabetes mellitus. The American Journal of Managed Care, 8(11), 950-958.
40. Sokol, M. C., McGuigan, K. A., Verbrugge, R. R., & Epstein, R. S. (2005). Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care, 43, 521-530.
41. Starfield, B., Weiner, J., Mumford, L., Steinwachs, D. (1991). Ambulatory care groups: A categorization of diagnoses for research and management. Health Services Research, 26, 53-74.
42. Vojta, C. L., Vojta, D. D., TenHave, T. R., Amaya, M., Lavizzo-Mourey, R., & Asch, D. A. (2001). Risk screening in a Medicare/Medicaid population: Administrative data versus self report. Journal of General Internal Medicine, 16, 525-530.
43. Weiner, J. P. (2003). Predictive modeling and risk measurement: Paradigms, potential and pitfalls. Retrieved from http://www.acg.jhsph.edu/ ACGDocuments/Weiner-BCBS-PredictiveModeling-2-6-03.pdf
44. Weiner, J. P., Dobson, A., Maxwell, S. L., Coleman, K., Starfield, B., & Anderson, G. F. (1996). Risk-adjusted Medicare capitation rates using ambulatory and inpatient diagnoses. Health Care Financing Review, 17, 77-99.
45. Wennberg, J., & Gittelsohn, J. (1973, December). Small area variations in health care delivery. Science, 182(117), 1102-1108.
46. Winkelman, R. (2006). Society of Actuaries Risk Adjuster Project. Presented at the Society of Actuaries Predictive Modeling Webcast Series - Part 4. Retrieved August 9, 2006
47. Zhao, Y., Ash A. S., Ellis, R. P., & Slaughter, J. P. (2002). Disease burden profiles: An emerging tool for managing managed care. Health Care Management Sciences, 5, 211-219.