Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. A. Identifying High-Risk Seniors


Identification underlies effective care systems for high-risk seniors. It is impossible to deliver effective treatments without first identifying who is likely to be at risk of adverse outcomes. In addition, it is essential to act on the results of identification efforts. People identified as facing high risks for adverse health outcomes need to be referred to the appropriate follow-up services, which could include more detailed assessments.

The variability among high-risk seniors makes the use of multiple approaches essential to effective identification. Symptoms and impairments can vary among individuals and over time, so any single method is likely to miss some high-risk seniors. In addition, multiple approaches are required to respond to the variation among seniors in their attitudes toward health and seeking care. All of the case-study MCOs had developed multiple identification methods.

Traditionally, in the fee-for-service and managed care sectors, high-risk seniors are identified as they enter the hospital or otherwise obtain care after the occurrence of a serious illness. In addition, physicians have long identified high-risk seniors over the course of regular office visits. Managed care has brought additional identification methods, including screening surveys and analysis of claims/encounter data. In addition, advocate groups have encouraged proactive identification that would promote self-referrals from high-risk seniors and referrals from their families and the community service organizations that provide assistance to seniors (Gold et al. 1998; Medicaid Working Group 1995; and Consortium for Citizens with Disabilities 1993).

Assessments are usually made by primary care physicians in the context of regular office visits. In fact, assessment and diagnosis are the basic elements of primary care practice. Specialized geriatric assessment clinics and home health visits are also used to assess care needs. MCOs that identify high-risk seniors through surveys or reviews of administrative data face the issue of how to use that screening data to determine appropriate follow-up. The screening data at our case study sites were generally intended to be used to identify people who should visit a physician as soon as possible, although this goal was not always met. We found virtually no evidence that information collected in screening surveys was used to develop clinical plans.

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