Triggers to Identify Patients Who Would Benefit from Interventions – High-Performing Practice ACTION TOOLS

THE CARE INTERVENTION SUBCOMMITTEE’S HIGH-PERFORMING PRACTICE STUDY IDENTIFIED SIX KEY ATTRIBUTES OF PRACTICES THAT WERE HIGH-PERFORMERS ON ED AND INPATIENT UTILIZATION. ALL PRACTICES USED SOME KIND OF DECISION RULE OR SET OF TRIGGERS TO IDENTIFY PATIENTS WHO WOULD BENEFIT FROM INTERVENTIONS (E.G., CARE MANAGEMENT, SELF-MANAGEMENT PROGRAMS; REMOTE PATIENT MONITORING; ETC.).

High-performing practices had systemic and robust ways of using their EHRs and population health data to target patients who were likeliest to benefit from team-based care programs or interventions. These practices used their data to scan for a set of conditions or characteristics and either produce a list or identify directly enter the patient eligibility and recommendation for a program in the EHR. As well, staff within the practices knew and could often recite the triggers from memory. Moreover, they knew their role and the actions that they needed to take when a patient was encountered that met the criteria.

Examples of Triggers Used in High Performing Practices

  • 4 visits/yr for uncontrolled diabetics; 2 for controlled
  • Age over 85
  • A1cs over 8 (uncontrolled diabetes)
  • Uncontrolled CHF
  • Unresolved depression
  • Recent heart attack or stroke
  • COPD diagnosis
  • Cognitive issue
  • Self-pay patients
  • Unmet SDoH needs
  • ADT notifying the practice of inpatient admission or ED use

Examples of Accompanying Processes Used When Patients Have Trigger Characteristics

  • The Care Manager adds themselves to the scheduling calendar for high risk patients and is
    included in the patient’s office visits (or virtual visits) so that the PCP is aware and can do a
    warm hand-off to the Care Manager.
  • Having a standard cadence for comorbid or complex patient with chronic disease. For example,
    in some practices, chronic patients who are in control are scheduled for two interactions per
    year and those not in control limits are scheduled for a minimum of four per year.
  • Automatic spirometry for asthmatics upon being roomed
  • Standing orders for A1c testing for diabetics

PDF: Triggers to Identify Patients Who Would Benefit from Interventions