PATIENT-CENTERED CARE Hot Spotter Report User Guide Overview The Hot Spotter Report is designed to give providers and care team members a heads up when their attributed patients appear to be at risk for inpatient readmissions, or could benefit from an intervention by the primary care team The Hot Spotter Report lists your patients at high risk who have been identified as likely needing care plans The report generally targets those with a recent inpatient admission as well as those with chronic diseases who have gaps in care Risk is determined based on variety of factors including readmission and chronic conditions High-risk patients are identified based on either an emergency room or inpatient visit or by diagnosis with one of five chronic conditions, along with a gap in care based on available claims data The Hot Spotter Report is updated daily to identify patients at risk for readmission, and monthly to identify patients at risk due one of five chronic illnesses: Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD) and Asthma (AST) Where to Find the Hot Spotter Report You can find the report on our Availity Portal under the Patient Centered Care Program heading Revised 5/21/2013
Reading the Hot Spotter Report Field New to report Patient: Name Patient: ID Patient: Gender Patient: Phone Months on Report Prospective Risk Score Description A patient who is on the report for the first time will have an X in this field Patient s first and last name Identification number assigned to the patient Displayed as M (male) or F (female) Patient s phone number Number of months the patient has been on the report, including the first date that the patient appeared on the report A number predicting future health care costs and utilization based on demographic factors (age, gender) and current chronic conditions and co morbidities (diagnoses codes from administrative health care claim data) Scores are updated monthly using DxCG software developed by Verisk Health The Prospective Risk Score (PRS) represents the relative risk of future health care costs and use over the next 12 months These scores account for the predicted influence of chronic conditions and co-morbidities on future health care costs and use A score of 1 represents an average member If someone has a score of 2 they are predicted to use twice the amount of medical services as the average member, and cost twice as much as the average member A score of 10 means the member is predicted to use 10 times the amount of services and cost as an average member 2
Prospective Risk Change Percent of change in the patient s risk score The readmission score is refreshed daily and the chronic risk is refreshed monthly on the Hot Spotter report Risk Change and Color Code: Less than 10%, no color From 10% to 20%, yellow cell More than 20%, red cell Readmission Risk Change: displays the value of difference between current month risk score and previous month A patient s predicted risk for an inpatient readmission within 90-days of a primary inpatient event Patient s risk is calculated with a WellPoint proprietary predictive model using: Current admission information Overall utilization history and cost risk Disease co morbidity Demographic data Patients admitted to the hospital are assigned a score that represents a percentage chance for being readmitted within next 90 days Primary Care Physician: Name Primary Care Physician: NPI The model uses claims data regarding chronic conditions, gaps in care, and utilization of health care services to assign the risk score The model also takes into account the patient s current admission information Provider s first and last name National Provider Identifier, a 10-digit identifier issued by the Centers for Medicare and Medicaid Services 3
Risk Model Chronic, Readmission, or Chronic & Readmission Risk model provided by Comprehensive Health Solutions analytics; used to identify patients who could benefit from a care plan Patients appear on the report based on one of three triggers that indicate they could benefit from a care plan: Readmission: if patient has recently been admitted and has moderate to high risk chance of being readmitted or a gap in care that can be addressed by a primary care physician they will appear on the report Chronic: If the patient scores higher than the general population in the prospective risk score, has one of the five core conditions, and has at least 1 gap in care they will appear on the report Five core chronic conditions are targeted: Diabetes, COPD, Asthma, Heart Failure and CAD Readmission AND Chronic: If patient was recently admitted, has a high risk of readmission and also triggers based on the chronic model Risk Driver 1 Risk Driver 2 Risk Driver 3 Risk Driver 4 Emergency Room Utilization: Visits Emergency Room Utilization: Last Visit Dt Emergency Room Utilization: Last Visit Diagnosis The top four risk categories for your patient Risk categories are associated with chronic disease, readmission or both Based on a risk model provided by our Comprehensive Health Solutions analytics Outlines potential gaps in care that are driving the prospective risk score higher Number of ER visits the patient had within the rolling 12 months Date of last ER visit within the rolling 12 months Diagnosis code used for the patient s last ER visit 4
Chronic Conditions Primary (1), secondary (2) and tertiary (3) chronic condition for your patient based on the our Comprehensive Health Solutions analytics risk model Top 3 diagnoses listed on claims Case Management History: Program The most recent care management program associ patient within the rolling 12 months Case Management History: Status The status of your patient s participation in a Case Management program Includes current status of program and the closure reason if applicable Disease Management History: Program The most recent disease management program associated with your patient within the rolling 12 months Disease Management History: Status Status of your patient s participation in disease management program Status indicators are: Participating, Declined with reason, Complete Includes current status of program and the closure reason if applicable UniCare Life & Health Insurance Company Registered mark of WellPoint, Inc 2013 WellPoint, Inc 5