Comments of Management models

Stratification of risks and case management


Risk stratification means the classification of individuals into categories in accordance with their probability of suffering deterioration in their health.

The most widely used approach to stratification is known as the Kaiser Pyramid (Figure 4), developed by Kaiser Permanente in the United States to categorize patients into three levels of intervention depending on their level of complexity. At the bottom of the pyramid, Kaiser places healthy members of the public for whom prevention and early diagnosis of disease are the priorities. At the second level, where patients have some form of chronic illness, the emphasis shifts to self-management, the appropriate administration of medication and health education. At the third level, patients identified as complex (3% to 5% of the total) are assigned care plans guided by case management efforts designed to reduce inappropriate use of specialist services and to avoid hospital admissions.

Some European public health systems, notably the NHS (National Health Service) in Britain, have tried applying the Kaiser model in their contexts (37-39). The method used to identify patients with complex diseases varies from model to model. The NHS tried adapting the US Evercare model (see details below) but because of the unavailability of data had to identify patients using eligibility criteria (40). Others subsequently followed predictive modeling (41) using a wide range of methods such as Adjusted Clinical Groups-Predictive Modeling (ACGs-PM), Diagnostic Cost Groups (DCGs), Patients at Risk of Re-Hospitalization (PARR 1 and 2) and the Combined Predictive Model (CPM) (42).

Figure 4. Kaiser Permanente risk stratification pyramid



Regardless of the approach, the initial step is the collection and analysis of demographic, clinical or cost databases to establish, for a given individual or group of individuals, the risk of suffering a specific illness or an event associated with deterioration in their health (43).

The event most frequently measured is unscheduled hospital admission, although many others may be employed, such as emergency room visits, drug costs and loss of independence. Stratification can also be performed on the basis of the different prevalence among different populations of risk factors based on unhealthy lifestyles (44).

The risk stratification technique arose for economic reasons, as insurance companies started to use it to create different products or premiums according to the risk profile of their clients, while avoiding the introduction of models that reject individuals based on previous conditions. In national health systems, risk adjustment and stratification allows for the differential allocation of health services and activities (preventive, corrective or compensatory) and resources, aiming to avoid critical system overload. In short, risk stratification models enable the identification and management of individuals who require the most intensive actions, such as elderly patients with multiple complex conditions. In these cases in particular, stratification seeks to avoid unscheduled hospital admissions (45), to optimize resource allocation (46), to promote patient self-management (47), to prioritize the intensity of interventions in all settings (48) and can even be used for the selection of participants in clinical trials (49).

Although the increasingly widespread application of electronic health records is facilitating risk stratification, the availability of precise information with low rates of data loss is still difficult to achieve in most settings. In many cases, resources must be invested in data transformation for analytical purposes. In others, the classification of illnesses is a common and major source of distortion. Misclassification, for instance, has been described in up to 30% of patients using the International Classification of Diseases (ICD) codes (50).

There are problems arising from the complex condition itself. Co-morbidity is generally assessed using scales that in some way add up the number of illnesses suffered by an individual, with weighting based on severity, such as the Charlson Index (51).

Some groups have proposed the selection of complex patient groups by means of associations of specific illnesses (52) although others claim that specific disease combinations are of lesser relevance than the burden of co-morbidity (53).

Stratification by frailty or illness has also proved useful during natural disasters, such as Hurricane Katrina in New Orleans. Although evacuation strategies stratified by level of economic income were applied, the elderly or chronically ill within each social stratum had fewer options for evacuation than healthy people (54).

Stratification is also fueling the increasing interest in case management, a concept that has its origins in the care of non-institutionalized psychiatric cases in the USA during the 1950s. Case management is a complex intervention, generally led by nursing staff, which covers a wide range of interventions including patient identification, the evaluation of problems and needs, planning of care in accordance with such needs, coordination of services, and review, monitoring and adaptation of the care plan. Case management is usually promoted either as a key component or as a complement to other elements within multi-component approaches (55-57).

Evercare is the cornerstone of one of the most widespread care coordination programs in the United States, with more than 100,000 individuals currently signed up across 35 states (58). Its basic principles are:

- Individual whole-person approach to elderly care is essential, to promote the
highest level of independence, well-being and quality of life, and to avoid adverse effects from medication (with the emphasis on poly-pharmacy).

- The principal provider is the primary care system. The best placed professional to implement the plan is a community-based nurse acting as clinical agent, partner, patient educator, coordinator and counselor. Only a third of work time is dedicated to direct patient care (59).

- Care is provided in the least invasive manner and context.

- Decisions are supported by data recorded using advanced technological platforms.

The first step in the model is identification of high-risk elderly patients, for whom an individual care plan is devised. Advanced primary nurses are then allocated a list of patients whom they regularly supervise. They are responsible for providing additional care, including admissions to nursing homes or hospitals.

Under the Evercare model, nurses direct and provide care, with the emphasis on psychosocial well-being. Participating  physicians must have experience and  skills in geriatrics, in particular in the  care of frail individuals. Transfer of care is minimized, and the proportion of care received at nursing homes increased. Early detection and surveillance programs are applied, with teams acting as the patient's representatives, in an attempt to obtain the maximum benefit in care from their medical insurance. The family is involved in patient care, with intense and consistent communication among family, professional team and nursing staff.

An evaluation of the system has demonstrated reductions of 50% in hospital admissions rates, without an increase in mortality, with cost savings and high levels of satisfaction (60).

In light of this success in the USA, in 2003 the British Department of Health decided to pilot an implementation of the Evercare model at 9 Primary Care Trusts (61).

A preliminary analysis identified a high-risk population including individuals with two or more hospital admissions over the past year. This group represented 3% of the population aged over 65, but accounted for 35% of unscheduled admissions for that age band. Surprisingly, many of these patients were not actively being dealt with by the ystem: only 24% were registered as cases by the district nurses, and only one third were known to social services. Curiously, 75% of the highest-risk population lived in the community, and only 6% and 10% in residential homes and nursing homes respectively.

The use of an adapted version of Evercare with a community focus in the NHS, and the differences between the healthcare contexts in the US and the United Kingdom, may have led to what seemed to be very different results. A formal evaluation through pilot experiments did not show a reduction in urgent hospital admissions, average hospital stays and mortality (62). The evaluation did, however, have many problems (63), and the seeming «failure» of the Evercare program in England may have been simply because there was no time to implement the program fully (it took several years in the US to achieve reduced hospital admissions) or because the means of selecting patients was inadequate. Despite the failures the NHS has persisted with case management of the frail elderly with complex chronic disease. This may be partly because qualitative evaluation by the same independent group who did the quantitative study showed that patients and carers liked the program very much, as did the nurses and doctors involved (64).

Existing comments

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Hola por favor podrias decirme como consigo este articulo tan interesante con bibliografia incluida , no lo puedo conseguir podeis mandarmelo a mi mail, o explicarme como lo hago, si alguien es tan amable gracias...
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Hola por favor podrias decirme como consigo este articulo tan interesante con bibliografia incluida , no lo puedo conseguir podeis mandarmelo a mi mail, o explicarme como lo hago, si alguien es tan amable gracias...
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El enfoque individual del paciente geriátrico es fundamental para evitar errores de medicación y efectos secundarios no deseados q en estos pacientes son de especial trascendencia. En estos pacientes, como es  conocido a través del estudio ENEAS, es alto el porcentaje de ellos que reingresan por algún efecto secundario de la medicación que tomaba. Para evitar esto, una de las tareas que desde los servicios de farmacia hospitalarios se está llevando a cabo es la Conciliación de la medicación al Ingreso y al Alta con el fin de evitar duplicidades, mantener durante el ingreso la medicación estrictamente necesaria, revisar toda la medicación del paciente (tanto la domiciliaria como la que le añaden en el ingreso en cuestión), estudiar interacciones, medicamentos UTB (Baja Utilidad Terapéutica) y aquellos que se cronifican sin necesidad una vez desaparecida la patología en cuestión, explicar al paciente cómo tomar sus medicamentos y hablar con ellos de posibles efectos secundarios que estén sufriendo e informarles de la nueva medicación, etc...

28/12/2014 Eva Martin Ruiz
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Es en este enfoque sobre el que se basa la actual gestión de casos en enfermería en Andalucía, desarrolladas por enfermeras de práctica avanzada que desarrollan su relevante y tan necesario tanto en atención primaria como no podía ser de otro modo, en atención hospitalaria. Los logros y resultados de este modelo de atención a pacientes crónicos complejos está dando muy buenos resultados, una pena el papel de la crisis en todas estas intervenciones….

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La estratificación es necesaria y ayuda a planificar desde la AP, y coordinarse con la atención especializada

La Gestora de Casos en la primaria tiene un papel activo y autónomo con una efecto positivo en las personas, comunidad y profesionales




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La estratificación del riesgo  de forma correcta es fundamental, se deben poner en nuestra mano herramientas prácticas para realizarla. Actuamos respondiendo a las demandas de la población, esta frase "sólo el 24% de ellos estaban registrados como casos por el personal de enfermería del distrito y sólo un tercio de ellos eran conocidos por los servicios sociales. Curiosamente, el 75% de la población de alto riesgo vivía en la comunidad " referida a la implantación del Evercare en el NHS hace que pensar.

En cuanto a la gestión de casos, creo que se debería potenciar más e incluir más aspectos, en la realidad diaria a veces se queda en que la EGC del hospital avisa de un alta de un paciente complejo a la EGC de AP

03/07/2012 Roberto Nuño
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Una descripción de la aplicación práctica de la estratificación poblacional que hemos hecho en el País Vasco la podéis encontrar aquí:

También se están haciendo aplicaciones interesantes con empleo de modelos predictivos en Comunidad Valenciana y Cataluña.

19/03/2012 Conchi Candela
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Es una gráfica esclarecedora la pirámide.

Compartir los cuidados con la persona - la cuidadora - las/los profesionales, desde el inicio a partes que evolucionan a medida de la complejidad y que eso redunde en disminución de costo, me parece muy relevante.. Me gusta

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Si la piramide Kaiser evidencia que el 5% consume la práctica totalidad de los recursos asignados a la sanidad, algo esta fallando. yo tengo experiencia en la gestion de casos y puedo corroborar que se reducen costes, ingresos imnecesarios, al tiempo que mejora la satisfaccion del paciente y cuidador. Se requiere de una buena comunicacion entre primaria y hospital para facilitar la continuidad asistencial, de forma que las altas en pacientes complejos son planificadas e informadas a los responsables en atencion primaria.

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Igual que existe la figura del gestor de casos, no me parecería mala idea que hubiera una figura paralela en los centros hospitalarios englobando 1 o varias especialidades, que evaluara desde ahí la estratificación del riesgo e hiciera un seguimiento de determinados casos junto con el gestor. Así el trabajo no estaría tan cargado sobre Atención Primaria, que realmente se lleva gran parte de la carga. Esta figura podría descargar también a aquéllos profesionales que han atendido al paciente durante su ingreso, pero que les cuesta trabajo el seguimiento posterior y la coordinación con A. Primaria.

Desde luego un sistema unificado que automáticamente definiera el riesgo, sería de gran apoyo

06/03/2012 Lola Nieto
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La estratificación de los pacientes en función de su pronostico, de su deterioro funcional, del nivel de dependencia, nos debe de ayudar a reorientar el sistema. Saber cuanto y que dar a cada enfermo en función del punto donde se encuentre dentro de la evolución natural de su enfermedad. Es crucial para la toma de decisiones, para marcar objetivos y para priorizar nuestras actuaciones. 

Habría que implantar sistemas automáticos que nos marcaran estos riegos, utilizar índices accesibles a todos los profesionales y los propios sujetos que nos ayudaran a optimizar los recursos.

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