The CAPC Payment Accelerator: A Joint Virtual Workshop for Home-Based Care Teams-CAPC Accelerator Population Stratification Considerations

CAPC Accelerator Population Stratification Considerations

Pdf Summary

The document provides guidance on population stratification for effective dosage of interventions in healthcare, particularly for palliative care. The guidelines are influenced by PACSSI models and adapted for specific program needs, focusing on efficient resource use and catering to patient care needs. It categorizes patients into high, medium, and low-risk levels based on care intensity, utilization, ADL dependence, palliative performance, medical conditions, and psychosocial factors. Each risk category is assigned a frequency of visits and phone or video calls, and specific indicators like hospital admissions or functional impairments.<br /><br />Key practical tips include:<br />1. **Stakeholder Input**: Understand and align with stakeholder concerns, and negotiate schedules if possible.<br />2. **Number of Categories**: Decide on the number of risk categories that fit the team’s preference and local culture.<br />3. **Risk Distribution**: Ensure that most patients fall into the medium-risk category as this is the average; educate clinicians on accurate prognostication.<br />4. **Assessment**: Assess and record current practices for baseline productivity and to identify areas for efficiency improvements.<br />5. **Reassessment**: Regularly reassess and re-categorize patients based on their evolving conditions.<br />6. **Service Model for Low-Risk Patients**: Develop reliable models for low-risk patients that include options like returning to usual care, alternative support programs, or scheduled telephonic follow-ups.<br />7. **Concordance**: Ensure team agreement on risk stratification protocols and use disagreements as improvement opportunities.<br /><br />The document emphasizes the dynamic nature of patient risk levels, encouraging ongoing evaluation and adjustment of care intensity to align with patient needs and optimize resource utilization.

Keywords

population stratification

effective dosage

palliative care

PACSSI models

risk categories

resource utilization

patient care needs

stakeholder input

assessment

reassessment