H&HN says:

“Much of the impetus for Denver Health’s shift in priorities came from a report out of Camden, N.J., which found that just 1 percent of the city’s population accounted for 30 percent of its health care costs. In a 2011 article in The New Yorker, Atul Gawande, M.D., chronicled how Camden health care leaders developed a comprehensive program to identify and serve those super-utilizers.

“’In that article, he really described well the dilemma we face in terms of [continually confronting] chronic medical conditions,’ recalls MacKenzie, who is an internal medicine doctor and also teaches at the University of Colorado School of Medicine. Inspired by the story, ‘we set out to avoid high-cost utilizations that we felt were preventable,’ McKenzie says.

“Using funding from the Center for Medicare and Medicaid Innovation, Denver Health set out to transform its primary care practice into one that uses population health strategies and predictive modeling to improve health care delivery and reduce costs. ‘We applied it to the entire population,’ MacKenzie says. ‘That was something we hadn’t seen done in other healthcare systems.”’

H&HN reported that Denver Health decided to divide its roughly 150,000-patient primary-care population  into four tiers:

  • “Tier One – Patients without a history of hospitalizations or chronic medical conditions.
  • “Tier Two – Patients accounting for health care expenditures four times greater than Tier One’s. Denver Health designated patient navigators for Tier Two, embedded behavioral health technicians and had social workers focus on this group.
  • “Tier Three – Patients with quadrupled health care costs compared with Tier Two. Members of Tier Three have multiple chronic medical conditions, may have mental illness and substance abuse issues.
  • “Tier Four – These are Denver Health’s ‘hot spotters,’ Tier Four often deals with homelessness, substance abuse and serious mental illness. Denver Health created a special outpatient clinic for this patient group, designated psychologists, nursing care coordinators and substance abuse counselors”

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