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This is a first step toward stratifying patients according to disease severity, comorbidities, treatments tried or successful, complications, and any of a number of characteristics that can enable providers at any scale to measure and begin comparative analysis of clinical, health economic or financial outcomes.
Organizations pursuing this stage are often seeking to answer key analytical questions such as:
What are our current Targets for Patients & Outcomes?
What Results are we seeing?
Are they Consistent?
Where are we seeing Under- or Over-Performance?
The following Action Plans are concrete steps organizations must consider for progressively achieving this stage.
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Achieving Accountable Care Executive Briefing
ACO IT Readiness Assessment Case Study
Patient Data Matching Strategy Case Study
Assemble Patient Identifiers and records of care for targeted Patient or Member populations
Identify categorical and descriptive attributes for characterizing both individuals and sets of Patients; perform basic population tallies and both quantitative and qualitative summaries
Identify most useful and informative attributes and criteria for defining Patient cohorts and other homogeneous Patient segments
Prepare for baseline assessment of patient cohorts and/or strata; define and identify potential performance metrics for segment analysis
Identify and assess multi-disciplinary, cross-functional, and/or multi-dimensional outcomes as baseline for initially individual, and ultimately shared, performance targets for ACO entities and participants
Identify ACO Parties & Roles
Identify key Providers and resources participating in care and service delivery for emerging population targets and candidate ACO members
Define and align Providers and other resources with care delivery roles, quantify and assess the value of their participation and contribution to the coordinated (and distributed) care processes and outcomes
Assemble baseline performance on specific measures, and designate targets for each appropriate segment, to be delivered and monitored at each appropriate organizational and resource level
Identify sources of best practices and standardized care plans for targeted implementation in specific disease areas, populations, geographic or practice locations, or service areas
Examine both standardizing/constraining and flexibility elements in care plan models
Proactively identify measures of adherence and/or excellence/best practices for executing targeted plans and their associated outcomes or impacts
Identify appropriate EBM guidelines specifically targeting patients, disease areas, populations, or service areas
Integrate EBM models and related resources into care delivery operations and systems
Define measures of adherence and/or excellence/best practices for executing defined EBM guidelines and their associated outcomes or impacts