How clinical intervention can improve the health of those at highest risk

The high-risk top 5 percent typically drive more than 50 percent of overall health care spending when absenteeism, disability and workers’ compensation are included.

Predictive analytics that weigh workers’ compensation, disability, incidental absence, and medical and pharmaceutical claims can be combined to create a risk index that provides early identification of individuals who will soon be both high-risk and high-cost. Clinical intervention can then be offered to those who need it most.

Smart Business spoke with Justin Schaneman, MS, vice president of Data Analytics, and Rene Sims, MSN, vice president of Clinical Services at HCMS Group, a WorkPartners affiliate, about how to create a holistic clinical prevention model, the second of two articles on leveraging integrated data and applying it to clinical interventions.

How does a holistic clinical prevention program work?

Individuals identified through predictive analytics should be invited to enroll in a clinical prevention program, based on the employer’s cultural preferences. This model uses a holistic approach beyond conventional disease management, which is typically triggered by specific conditions such as diabetes or cancer. The data for high-risk individuals consistently shows that costs associated with multiple conditions often produce a cascading effect. Addressing all the conditions, including work, family and social issues helps individuals navigate the health care system and make better decisions about their treatment, leading to fewer relapses and a more sustainable recovery.

Individuals can be invited through a series of outreach calls and letters. Enrollment rates are typically high because these individuals often feel desperately lost in the fragmented health care system and welcome the additional resources.

In this model, a nurse serves as the primary point of contact and continually evaluates the individual’s needs while adjusting the action plan to address those needs. Medications are reviewed by a pharmacist to assist with issues, such as a need for lower-cost options, negative side-effects and the risk of interactions between multiple medications. A medical research librarian provides information to help members take control of their health and make health care decisions that lead to improved outcomes.

What kinds of results can be expected?

In our experience, within a year of enrolling, about half of participants see significant improvement in health, risk and utilization metrics. It may take longer for participants with more complex situations to ‘graduate.’ Measures of success include engagement with a primary care provider; a decrease in the number of prescription drugs, specialists and lost work days; increased productivity at work; and improved quality of life.

HCMS conducted a pre/post enrollment study of 3,864 enrollees who went into a clinical prevention service from 10 companies in 2016. The companies ranged from 500 to 21,000 workers across multiple industry sectors. The most drastic decreases occurred in the number of medical tests, which correlated to a significant decrease in visits to multiple medical providers. The second biggest impact was a reduction in the number of medications. In some cases, the number of diagnoses decreased by the time an individual graduated from the program.

It’s common for people in high-risk groups to experience high-cost events for a matter of months and then begin to recover. Typically, there is a rapid increase in the costs of absence, disability and health care, followed by a rapid decline. However, for individuals enrolled in a clinical prevention model, the decline starts significantly sooner and falls significantly more. This results in tangible cost savings during the first year after intervention.

By providing high-touch clinical support and actionable information across all dimensions, this model empowers individuals to take charge of their health and improve the quality of their life.

As big data opportunities expand in the workforce health arena, advanced analytic and predictive modeling is becoming even more relevant and can improve outcomes for both the employee and employer. The key is to partner this predictive power with a clinical service that can leverage that intelligence effectively, targeting individuals who will benefit from the service.

Insights Health Care is brought to you by UPMC Health Plan