Clinical Corner

Best Practices For Managing Chronic Conditions In High-Risk Patients​

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Effectively managing patients with chronic conditions, particularly those with multiple comorbidities, is one of the most challenging yet important aspects of delivering on the promise of value-based care. Of course, high-risk patients are more likely to experience complications, hospitalizations, and increased healthcare costs.

 

In this edition, we’ll highlight strategies for identifying and managing high-risk patients early, including the tools and resources we use at Genuine Health Group, such as the Johns Hopkins Adjusted Clinical Groups (ACG) System—which is a risk adjustment algorithm—and our targeted Chronic Care Management (CCM) program. Our goal is to help you provide more personalized, robust care to the sickest and most complex patients in your practice.

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Proactively Identifying High-Risk Patients With The Johns Hopkins ACG System

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Using Johns Hopkins Risk Adjustment Algorithms

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At Genuine Health Group, we utilize the Johns Hopkins ACG System to stratify patient risk and identify individuals who are most likely to benefit from enhanced care management. The system uses a comprehensive set of clinical, demographic, and social factors to predict health risks and outcomes, enabling us to identify patients at high risk for complications or hospitalizations. This system helps us focus on patients who require more intensive monitoring and intervention, ensuring that we allocate resources to those who need them the most.

Identifying High-Risk CCM Patients​

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Our Chronic Care Management (CCM) program specifically focuses on the sickest patients with the most complex circumstances—those with multiple chronic conditions and a high likelihood of requiring frequent medical intervention. By identifying these patients early, we can provide them with more personalized, proactive care.

 

The algorithm helps us categorize patients with high disease burden, ensuring we are prioritizing those most at risk for hospital readmissions, complications, and declining health.

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Employing Risk Stratification For Early Intervention​

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Leveraging these tools, we can identify high-risk patients during routine visits, allowing you to implement early interventions, such as tailored care plans, medication reviews, and referrals to specialists. This early identification can prevent avoidable exacerbations and reduce unnecessary hospitalizations.

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Best Practices For Coordinated Care Of High-Risk Patients

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Developing Comprehensive Care Plans

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For high-risk patients identified through the Johns Hopkins ACG System and CCM program, developing a comprehensive, multidisciplinary care plan is essential. This includes addressing the full spectrum of a patient’s health, including chronic disease management, mental health, medication management, and social determinants of health. Collaborating with specialists, care coordinators, and community health workers ensures that patients receive the appropriate level of care.

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Coordinating Care And Follow-Up

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High-risk patients often require frequent follow-up and care coordination across multiple providers. Through our Accountable Care Organization's (ACO) care coordination team, you have access to resources that facilitate smooth transitions of care—whether from the hospital to home, or from one specialty to another. Ensuring that high-risk patients are not overlooked after discharge or between visits is key to improving outcomes.

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Utilizing Data For Continuous Monitoring​

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As part of the ACO, you have access to patient-level data and reports that help you track high-risk patients across the continuum of care. This data includes information from the Johns Hopkins algorithms, which can help you monitor patient progress, identify emerging risks, and adjust care plans accordingly.

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Medication Management And Adherence

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Optimizing Medication Regimens

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Many high-risk patients are on complex medication regimens that require ongoing adjustments. By leveraging pharmacist support and conducting regular medication reconciliation at every visit, we ensure that high-risk patients receive the most effective medications while avoiding unnecessary polypharmacy. The CCM program also focuses on ensuring that medications are tailored to each patient's specific needs, helping to reduce adverse events and improve adherence.

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Simplifying Medication And Tracking Adherence

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For high-risk patients, simplifying medication regimens can improve adherence. We encourage the use of pill organizers, digital medication reminders, and home visits from pharmacists to ensure that patients take their medications correctly. You can also use tools like the Morisky Medication Adherence Scale to assess patient adherence and work with your patients to address any barriers they may face in following their medication regimen.

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Addressing Mental Health In High-Risk Populations

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Integrated Behavioral Health Services

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Many high-risk patients also suffer from mental health conditions, which can complicate the management of their chronic diseases. We recommend screening for depression, anxiety, and other mental health conditions at regular intervals. By integrating behavioral health screening into your care approach, your patients will receive the support they need to manage both physical and mental health conditions simultaneously.

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Collaboration With Behavioral Health Providers

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Genuine Health’s ACOs offer resources for connecting your patients with mental health professionals in your community or within your care network. Behavioral health support can improve adherence to treatment plans and enhance your patient’s overall well-being.

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Patient Education And Empowerment

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Empowering Patients Through Education

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Providing high-risk patients with the knowledge they need to manage their conditions is essential for long-term success. Through educational materials developed by Genuine Health’s ACOs and regular discussions during appointments, patients come to understand their conditions, medications, and necessary lifestyle changes. Setting goals, such as reducing A1C levels or improving physical activity, can help patients feel more in control of their health.

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Engaging Caregivers And Family Members

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Many high-risk patients rely on caregivers for assistance. We recommend involving caregivers in care planning and education, providing them with the tools to support patients in managing their conditions at home.