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How to lower costs and provide better care for high-risk members.

Rightway extends a special focus to members who are considered ‘high-risk’. This blog post, written by Rightway’s Director of Data Science, Daniel Feller, PhD, provides an overview of high-risk member management.

Photo of a woman at a desk with her laptop, looking at her phone

Introduction.
It is well established that a disproportionate amount of healthcare spending is associated with a small percentage of the population - often persons with one or more chronic conditions such as diabetes or heart disease to name a few. Clinical care navigation solutions like Rightway extend intensive resources towards these members to ensure that they receive the appropriate medical and support services. Rightway’s proprietary personalized clinical navigation services have been shown to reduce healthcare costs among this population.

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Rightway’s approach to risk classification.
Rightway’s proprietary risk scoring methodology incorporates multiple data sources to classify members as either ‘rising risk’ or ‘high-risk’. First, medical and pharmacy claims provide our machine learning algorithm an ability to analyze each member’s longitudinal medical history and identify medical conditions that are either active or deteriorating. This data contains indicators on demographics, diagnoses, procedures, prescriptions, and historical healthcare spending. Second, user surveys that live within the Rightway Navigation platform provide insight into self-reported conditions that are not referenced in claims data, as well as behavioral and lifestyle information (e.g., nutrition and exercise habits). Third, our smart clinical, mobile-first solution also analyzes employee chats in the event that a member has disclosed to a Rightway clinical guide that they have a chronic or acute condition.

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The right way to manage rising risk and high-risk members.
Once identified, rising- and high-risk members become a focus for Rightway’s team of clinical and health guides. Our foremost goal is to ensure that at-risk members are aware of Rightway and understand the clinical / mental health and overall wellbeing value we can provide for them. The objective is to assist these members to the full extent of Rightway’s capabilities in order to ultimately help with treatment compliance, medication adherence, and improve overall health outcomes. Towards this goal, members who receive the most acute risk classification - hereafter classified as ‘high-risk’, receive intensive outreach from Rightway in order to direct them to better care. Our clinical guides reach out to these members directly via chat, phone, text, and email to inquire whether assistance is needed. This is our most intensive strategy. Among members who are considered ‘rising risk’, often members with a chronic condition who may have suboptimal preventative care compliance - we mail promotional material and handwritten notes directly to their mailboxes.

A member journey: why risk classification works.
The scenario.
Jane, a 39 year-old employee, was flagged as ‘high-risk’ after Rightway’s algorithm identified her as a diabetic who lacked a primary care provider visit and an HbA1c in over a year.

The approach.
Upon ‘high-risk’ identification by our algorithm, a Rightway clinical guide reviews Jane’s member profile in order to best personalize our proprietary outreach approach when introducing Rightway's services. These outreach attempts are conducted on a regular and ongoing basis until we have connected with the member.

The solution.
During the encounter, Jane learned more about Rightway’s services including help finding and scheduling care with a new primary care provider and condition management. Her clinical guide compiled a list of top-rated, in-network primary care providers within a 10-mile radius and sent her those options via our in-app chat. Rightway called the provider of choice to schedule Jane’s appointment, educated Jane about insurance coverage / cost, and prepped Jane for her visit. After the visit, the health guide followed up with Jane to ensure it went well and described the additional health and wellness benefits available through her employer and Rightway. Jane’s clinical guide is now her trusted, go-to advisor throughout her care journey.

If you'd like to learn more about Rightway or Rightway's high-risk engagement strategy, please get in touch today.

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