Most organizations already have the data they need to identify their most actionable patients—they just need to leverage it a bit differently. The first step aligns with what most organizations do already: leverage a holistic suite of risk factors, both clinical and non-clinical, to create inclusion criteria.
But inclusion criteria will get you only so far. The likely result is a group of patients that is larger than the average organization can fully support with high-touch services—and many patients for whom costs will be difficult to inflect. Identifying actionable patients requires a second step: overlay exclusion criteria to filter out patients whose high cost or utilization is out of the health system’s control. Such patients often require a different care model that necessitates costly, longitudinal support.
Accounting for available resources
Identifying actionable patients cannot be divorced from organizational bandwidth. To truly be “actionable,” the number and type of patients identified must align with an organization’s available services and clinical capacity.
For example, one organization we work with, recognizing their limited number of care managers, used inclusion and exclusion criteria to segment patients by “care coordination burden.” The organization then reallocated RNs to the practices where patients with the greatest care coordination burden were located.
By acknowledging resource constraints early in their risk stratification efforts, organizations can selectively define what constitutes “actionable” and then deploy resources to where they are needed most.