IDENTIFICATION

The goal of identification is to match patients to targeted, well-defined interventions that are likely to improve the lives of the patients while controlling costs. Patient identification begins with an explicit statement of what the intervention is. What kind of patient is likely to benefit? What is the clinical reason a patient should benefit from this kind of intervention? What results should be expected from a successful engagement? Explicit patient identification may include the following kinds of criteria:

• Illness burden
• Diagnoses
• Co-morbidities
• Risk for future high cost
• Projected future cost
• Etiology of diseases
• Chronic co-morbidities
• Frailty
• Fall Risk
• End of life risk
• Risk of inpatient admission
• Risk of intensive care admission
• Risk of long term admission
• Concurrent utilization
• Inpatient cost
• Inpatient metrics (LOS, frequency, readmits, severity, surgery, etc.)
• Outpatient cost
• Outpatient metrics (Procedure, frequency, severity, surgery, etc.)
• Professional cost
• Physician metrics (Specialty, PCP status, procedures, severity, frequency, etc.)
• SNF cost
• SNF metrics (LOS, frequency, severity, care giver availability, etc.)
• Treatment compliance to evidence based medicine practices
• Rx compliance
• Gaps in prescriptions
• Number of specialists
• Number of generalists
• PCP determination