Predictive modeling software helps case managers understand patient populations

The powerful data analytic tools used for predicting patients at risk for high healthcare utilization, healthcare costs, and mortality are essential to a successful population health model of care. Case managers have an important role in the data gathering and analysis for these various predictive modeling tools.

Initially, the healthcare plans predicted patients at risk for overutilization and high costs through claims data. The data was accurate but often at least two or three months old when it was deemed necessary to assign a health plan case manager to the patient. Patients with behavioral health and medical diagnoses are not managed by the same health plans, and the data integration may take longer than the clinical integration, which is not helpful to our most complex patients with medical, behavioral, and social needs. But the case manager can mitigate these needs with on-time intervention.

Predictive modeling stratifies the population according to risk with the goal of implementing an effective intervention prior to incurring additional adverse conditions, outcomes, and costs (Mullahy, 2017). The software programs that make predictive modeling possible also allow health systems and health payers to generate reminder letters to patients and/or beneficiaries, prompting them to schedule important diagnostic tests or even to fill prescriptions that are low.

Predictive modeling also directs the case managers to the rising-risk and the highest-risk patients. Case managers are valuable resources with quantifiable skills. The case manager in the population health model may work with individual patients, and also direct a team of case managers and case manager assistants or navigators to work together with a large group of patients.

Case managers are not just on the receiving end of the predictive modeling data collection and analysis. The need to have real-time data is increasingly important to a successful population health model. Case managers across the continuum are completing comprehensive case management assessments within electronic medical records. The data from the assessments is captured in the predictive modeling tool and used to provide real-time data about patients who are presenting to hospital emergency departments and medical practices. If the information system allows, electronic warnings and other tools alert caregivers that the patient requires case management services or they are already under case management service and have a case management plan.

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.