Jim Lloyd, JD, MPP and Rachel Davis, MPA

October 24, 2019

Health care stakeholders across the country are challenged to improve care and reduce unnecessary utilization for the nation’s highest-need, highest-cost populations. A variety of approaches exist for determining how to best target resources to this population, but one idea that has recently caught the attention of individuals participating in the Center for Health Care Strategies’ Complex Care Innovation Lab (CCIL) is that of impactability. Rather than identifying patients based solely on previous cost or utilization history, the concept of impactability emphasizes that programs should also consider how patients will likely respond to interventions and what strategies are needed to effectively engage them in care.

Evolent Health, a health care analytics company, suggests three dimensions of impactability:

  1. Identifying patients who are most likely to have a specific future event;
  2. Engaging patients using an analytically driven, patient-centered approach; and
  3. Implementing and optimizing evidence-based interventions to support these patients.

This idea holds promise not just for helping programs refine how they identify high-need, high-cost populations, but also for identifying those who are defined as “rising risk” — individuals who are not yet considered “high-risk,” but are on a trajectory to becoming so.

Since January 2019, a subset of CCIL sites — Boston Health Care for the Homeless Program,  the Camden Coalition of Healthcare Providers, CareOregon, the Center for Health Care Services, Denver Health, Johns Hopkins Healthcare, Maimonides Medical Center, and University of California-San Francisco — have been focused on identifying their rising risk population and developing effective interventions for them. The concept of impactability has influenced sites’ thinking about how to conceptualize both their rising risk and high-need, high-cost populations.

Early Returns in North Carolina Using an Impactability Score

One CCIL member, Community Care of North Carolina (CCNC), has already been pioneering an impactability framework to identify patients in its complex care program with underlying conditions or behaviors that are amenable to CCNC interventions. Recognizing that CCNC, like many health care programs, was operating in a resource-limited environment, Carlos Jackson, PhD, Chief Data and Analytics Officer at CCNC, explained that the organization began wondering not just who its high-risk patients were, but which individuals would respond most positively to its interventions.

In order to understand how CCNC could maximize its programmatic resources, Dr. Jackson and his team developed a “Complex Care Management Impactability Score” linking a patient’s predicted future risk with an assessment of the underlying causes of that risk and interventions that can be used to address those causes. The score uses cost and utilization data from North Carolina’s claims and administrative files, but also incorporates data from CCNC’s Care Management Information System, a statewide database that includes patient information drawn from standardized assessments, screening tools, and patient care plans. Ultimately, CCNC uses the impactability score to conduct an “impact segmentation” of its patients and target services to those identified as potentially the most responsive to the intervention.

CCNC has achieved impressive results: In 2018, a study of its impactability model demonstrated a return on investment that was two to three times higher than other stratification approaches, including methods that narrowly focus on emergency department or inpatient utilization.

The Benefits of Using an Impactability Frame

As demonstrated by CCNC, a focus on impactability can assist organizations in refining their approaches to care for a variety of populations, including how they identify “rising risk” populations. Analyzing impactability can help organizations understand where best to focus their resources, and how to identify areas where an organization is ill equipped to address certain patients’ needs. This concept can help organizations further refine their understanding of which patients are more likely to respond to interventions designed to disrupt their trajectory to becoming high-need, high-cost.

Organizations can also use an impactability analysis as a tool to support health equity efforts, as the concept identifies patients for intervention based on “objective criteria rather than the attentiveness of the physician.” An impactability analysis can also identify opportunities to improve health care access for patients who are experiencing gaps in care, since finding a rising risk or high-risk patient who is not responding to an intervention could signal an opportunity to fill that gap. As a result, an impactability approach not only identifies patients for whom the identified set of interventions can help, but can assist organizations in refining  workflows and outreach efforts to improve the success of the intervention.

Key Considerations

While impactability provides a compelling lens for identifying potential rising risk patient subsets, there are considerations that organizations must keep in mind when taking this approach:

  • Clarify upfront what outcomes are desired. Impactability measures the potential response to a particular set of services, and so understanding what outcome the organization will target can help focus the organization’s efforts on those services.
  • Understand the connection between impactability and available resources. Impactability measures what a specific set of tools may influence. Thus, adhering too strictly to an impactability score could cause organizations to look past patients with needs they could effectively address with a different array of services and/or resources. Because of this, some CCIL organizations have discussed that perhaps a better way to describe this identification and stratification approach is that it predicts which patients are “responders” and “non-responders.”
  • Consider a broad set of traditional and non-traditional data sources. Organizations should be confident in their ability to obtain access to the necessary datasets and be able to conduct such an analysis. CCNC uses medical, behavioral, and claims data; admissions, discharge and transfer data; and laboratory and immunization data to generate their analysis, and has the internal capacity to “crunch the numbers” and produce the information that providers can use.
  • Present information in actionable form. The reports produced for providers and care team members should be in a form that they can use to effectively conduct outreach, identify the patients, and deliver the services.

Looking Ahead

As the health care field increasingly embraces value-based care, effectively targeting resources with an eye toward return on investment is paramount. The concept of impactability holds promise as a strategy through which organizations can: (1) maximize the impact of their resources; (2) identify populations whose needs are not being met by current services and/or engagement approaches; and (3) highlight where additional services and resources are needed. With sites such as CCNC leading the way, the opportunities to use an impactability lens to help refine complex care and rising approaches are vast. As the CCIL’s work and the Rising Risk initiative advances, CHCS looks forward to sharing lessons from the participating sites.

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