You asked, ConcertoCare answered: Impact Summit session Q&A spotlight

Our annual Impact Summit is a chance for leaders from our client organizations around the nation to join together to share their successes and gain guidance for the coming year.

At our most recent Summit, our exceedingly impressive clients celebrated the wins that they’ve experienced through collaboration with MedeAnalytics. After each of the presentations, attendees had the chance to learn more about these stories by asking specific questions of the presenters. We found many of the Q&As riveting and highly educational, and we hope you do, too.

First up: ConcertoCare!

Impact Summit Session Spotlight: Leveraging Predictive Analytics to Reduce Hospitalizations and Improve Population Health Outcomes at ConcertoCare

Q: Why are social determinants of health critical to delivering high quality patient care?

A: Drivers of wellbeing include – but are certainly not limited to – the abilities to:

• Get transportation to get to one’s medical appointments
• Access to and affordable healthy food and clean water
• Adhere to dietary requirements and medicine regimens for certain conditions
• Secure consistent housing

There is simply no way to separate a patient’s ability to stay healthy from those social influences, so it is essential to care about and consider those factors in every interaction. If basic necessities are not met, patients will likely face a series of readmissions and failure to thrive.

Another angle we come at this from is that our population is often fully or partially homebound, so we must think a lot about community isolation, the need for companion care, and the importance of supporting our patients’ caregivers. These pieces are not typically brought up in conversations about social determinants of health, but we know that they are equally important to keeping our patients’ foundations stable and allowing them to age in place.

Q: Do you share the data and insights from your population health and care management platforms with external providers, PCPs, and/or other stakeholders?

A: Yes – we often use the information we glean from our own platforms to contextualize our actions and needs to external partners, plans and providers. It provides a comprehensive, longitudinal view of populations that is often not accessed or analyzed by those we work with.

Q: How do you see patient outcomes being impacted by data and analytics solutions?

A: We take on risk and accountability for a large population. We want to make sure we’re doing right by patients and giving them care that’s appropriate for their needs and situations. We are very cognizant of trying to match the right interventions to the right patients and making sure the interventions are impactful and efficient.

To accomplish these objectives, we leverage multiple data sources – clinical data, claims data, PBM data, patient-reported outcome measure data, and any other data sources that we can get our hands on. Once the data is collected, we apply algorithms to really understand which patients are appropriate for which interventions and what the appropriate care team composition is for our patients. We also use trends to identify appropriate frequency or cadence of outreach for our patients. Real-time data allows us to adjust many of these components quickly, enabling us to dynamically shift with our patients as their conditions, acuity or situations change.

Q: Where are you using predictive analytics to improve patient care?

A: From the value-based care lens, we use predictive analytics to identify patients showing early signs indicating increased likelihood of hospital or ICU admission. When a patient’s data places them within these parameters, we can deploy appropriate interventions to their home, ultimately supporting their wellbeing and minimizing unnecessary hospital visits.

One specific example of how this is deployed is what we call our geriatric predictive score. Though almost all the patients that we take care of at ConcertoCare are high risk, we still need real-time insight into who is needing extra support or more focused care. We leverage the geriatric predictive score to think through which patients are most likely to get into clinical trouble or need extra clinical support. This enables us to assess a patient’s frailty, their full risk issues around dementia or cognitive impairment, issues around social determinants of health, level of caregiver support, and many other factors to assess the patient’s stability in real time and to titrate our level of support.

Finally, predictive analytics also allows us to make better decisions and estimations regarding needs and trends in staffing, supply chain, and sites of care.

Q: With all the integration of services, providers, processes and data flows, how do you manage security and audits?

A: We have entire data security and compliance teams to ensure we:

• Have the appropriate certifications
• Adhere to regulations as a provider in the health plans network receiving the data exchange
• Go through regular audits to prove security levels and compliance
• Offer ongoing training and education on cybersecurity guidelines

Our deep commitment to patient privacy and data security carries throughout everything we do.

Q: Are you incorporating genomic data into any of the care you provide or trends you look for?

A: Genomic data is a bit ahead of where we’re at right now, but our model does take a very customized approach to each patient based on the data we have about them. That data does not include genetic code, but we collect a lot of data and personalize our approach to every patient in a way that I’ve heard described as personalized population health. This entails using comprehensive, longitudinal data about our patients, including religious affiliation, social situation, health history, language proficiency, community support, and more.

Thank you to Dr. Brian Davis and Dr. Amy Flaster of ConcertoCare for sharing their insights during our annual Impact Summit. Learn more about ConcertoCare’s story here.