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New Arrows in the Quiver for Targeting Care Management: High-Risk Versus High-Opportunity Case Identification

Bernstein, Richard H. MD

Journal of Ambulatory Care Management: January-March 2007 - Volume 30 - Issue 1 - p 39–51
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“Care management” purposefully obscures the distinctions between disease and case management and stresses their common features: action in the present to prevent adverse future outcomes and costs. It includes identifying a high-need population by referrals, screening, or data analysis, assessing those likely to benefit from interventions, intervening, evaluating the intervention, and adjusting interventions when needed. High-risk individuals can be identified using at least 9 techniques, from referrals and questionnaires to retrospective claims analysis and predictive models. Other than referrals, software based on the risk-adjustment methodology that we have adapted can incorporate all these methodologies. Because the risk adjustment employs extensive case mix and severity adjustment, it provides care managers with 3 innovative ways to identify not only high-risk individuals but also high-opportunity cases.

Mt. Sinai School of Medicine, New York; and CareAdvantage, Inc, Iselin, NJ.

The author acknowledges assistance from Jon Eisenhandler at 3M Health Information Systems for his technical review and evaluation of CRGs' most recent r2 performance and from William Vennart, MD, MBA, Ellen Freedman, BSN, MPA, MBA, and Sheila Van Daly, BSN, at CareAdvantage for their manuscript review and valuable comments.

Corresponding author: Richard H. Bernstein, MD, CareAdvantage, 485-C Rte One South, Iselin, NJ 08830 (e-mail: rbernstein@careadvantage.com).

© 2007 Lippincott Williams & Wilkins, Inc.