Population Insights2019-01-29T22:18:12+00:00

CareJourney’s Population Insights tool meets the needs of a variety of ACO users

A queryable tool built on the CMS-supplied CCLF files for a portfolio of clinically-relevant insights at the patient-level, to help measure performance and surface care intervention improvement opportunities for ACOs.

CareJourney Guided Analysis

  • Quarterly Expense and Utilization (QEXPU) financial reports built up from the claim-level
  • Operational dashboard highlighting KPIs across the most impactful measures of the ACO
Icon Data Analysts

CareJourney Self-Directed Analysis

  • Build and publish reports on enriched datasets using a flexible interface
  • Datasets including: encounters, patients, providers
  • Open source algorithms enrich datasets with clinically relevant labels
Icon Chief Medical Officers

CareJourney Care Models

  • Monitor compliance with prescribed care models across: ACO, practices and providers
  • Enrich longitudinal patient records with clinically relevant segmentation to prioritize high value outreach
Icon Care Coordinators

CareDirect Worklists

  • Operationalize care models by delivering worklists to the appropriate action-takers
  • Provide permissions for practice and provider-level staff to view appropriate sets of patients

Designed for:
Operational Directors


Designed for:
Data Analysts


Designed for:
Chief Medical Officers


Designed for:
Care Coordinators

CareJourney Guided Analysis

  • Quarterly Expense and Utilization (QEXPU) financial reports built up from the claim-level
  • Operational dashboard highlighting KPIs across the most impactful measures of the ACO

Designed for:
Operational Directors

Icon Data Analysts

CareJourney Self-Directed Analysis

  • Build and publish reports on enriched datasets using a flexible interface
  • Datasets including: encounters, patients, providers
  • Open source algorithms enrich datasets with clinically relevant labels

Designed for:
Data Analysts

Icon Chief Medical Officers

CareJourney Care Models

  • Monitor compliance with prescribed care models across: ACO, practices and providers
  • Enrich longitudinal patient records with clinically relevant segmentation to prioritize high value outreach

Designed for:
Chief Medical Officers

Icon Care Coordinators

CareDirect Worklists

  • Operationalize care models by delivering worklists to the appropriate action-takers
  • Provide permissions for practice and provider-level staff to view appropriate sets of patients

Designed for:
Care Coordinators

Operational Dashboard

Customize to track key performance metrics for financial, quality, and care model measures with slices by time period and network hierarchy.

Population Insights: Operational Dashboard

PMPY Insights and Exception Scanning

View PMPY by expenditure type with insight into year over year trends, outliers, and performance above or below benchmark – all at the doctor, practice, network and ACO level.

The Impact of Transitional Care Management (TCM) Services

QEXPUExceptionScanning

Tracking TCM Services in CareJourney

QEXPU ExceptionScanning

ACO Category Breakdown

Dynamically explore cost trends for the ACO by category of spend in one comprehensive view with investigative reports into the following:

  • Spend subcategories (ex – imaging, drugs)
  • Spend drill-down by network, practice, provider, and facility
  • Quarterly trends
  • Risk-based, patient segment spend
Population Insights ACO Category Breakdown

Open Patient Segmentation Models Available Through Research Collaboratives

Population Insights includes an open, peer-reviewed patient segmentation methodology that identifies the “frail elderly” as the largest proportion of high-cost patients.

Note: The researchers started with the list of 29 key chronic disease outlined by CMS in their measure for unplanned admissions for patients with multiple chronic conditions. They defined 9 conditions as “complex conditions:” Acute Myocardial Infarction / Ischemic Heart Disease, Chronic Kidney Disease, Congestive Heart Failure, Dementia, Chronic Lung Disease, Psychiatric Disease, Specified Heart Arrhythmias, Stroke, and Diabetes. They defined the remaining 20 conditions as “other non-complex conditions.”

http://www.sciencedirect.com/science/article/pii/S2213076416302287

Care Models: Clinically-Relevant Interventions with Evidence-Based ROIs

A Journal of the American Medical Association (JAMA) paper analyzed over 18 million TCM-eligible discharges over a three-year period to quantify the impact of compliant TCM services on post-discharge spend, mortality rate, and readmission rates.

The Impact of Transitional Care Management (TCM) Services

Post-Discharge Spend, 31-60 Days After Eligible Discharge

Population Insights TCM Chart

Post-Discharge Mortality Rate, 31-60 Days After Eligible Discharge

Population Insights TCM Chart

Tracking TCM Services in CareJourney

% Compliance of TCM-Eligible Discharges, by Follow-Up Type per TIN

Population Insights Tracking TCN

Summary: Furnishing TCM services has proven to significantly lower post-discharge spend, mortality rates, and re-admission rates. Using CareJourney’s suite of products, our members are able to track TCM compliance at different organizational levels, filter on high-need high-cost patient segments for targeted interventions, and benchmark their compliance against regional and national ACOs.

Source: Bindman AB, Cox DF. Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries.
JAMA Intern Med. 2018;178(9):1165–1171. doi:10.1001/jamainternmed.2018.2572

Unnecessary Spend: Avoidable Emergency and Impactable Admissions

Population Insights tracks potentially avoidable ED and impactable admissions using open logic from NYU and AHRQ.

Population Insights: Avoidable Visits

Profile Lists and Scorecards

View lists of key performance metrics from claims and open data for the following:

  1. Acute Facility
  2. Post-Actute
  3. Practice
  4. Provider
  5. Patient
  6. Claim-line
Population Insights: Profile Lists and Scorecards

Interested in Learning More?

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