Create a High-Risk List

Establish a mechanism to identify those patients at greatest risk of being hospitalized or going to the emergency room (i.e., create a high-risk list), in an attempt to intervene before they do so.

Best practices:

1. Create a workflow/process for adding patients to the high-risk list

To eliminate uncertainty, create a streamlined process that clearly indicates how a patient gets added to the high-risk list as well as who can decide whether a patient is considered high-risk.

  • Tip 1: Assign a point-person to be manager of the high-risk list and have a back-up in case that person is out of the office. This person will receive the names of high-risk patients from other providers and be responsible for adding patients to the list. Most sites assigned a nurse (ex. RN, Nurse Navigator, Infusion Nurse, or NP) to this role.
  • Tip 2: A medical doctor doesn’t have to be the only staff member allowed to decide which patients get added to the high-risk list. Many clinics allowed all IBD providers – medical doctors and advanced practice providers – to make this decision.
  • Tip 3: Choose whichever workflow, process, or system that works best for your clinic, whether that is establishing a formal identification process within your Electronic Health Record (EHR) system or simply sending an email to your point-person. It’s not important how you get the high-risk patient on the list, it’s that you get the patient on the list.

Examples:

The Oregon Clinic Gastroenterology South - “Any provider, which in our practice is defined as a medical doctor or an advanced practice provider, can determine which patients get added to the high-risk list. We set up a system in our electronic medical records where the provider can flag a high-risk patient. This information then goes to the nurses and the nurses put that patient on the high-risk list. In our clinic, the nurses are the ones physically managing who comes on and off the list.”
UC San Diego – “In our clinic, a medical doctor identifies a high-risk patient and sends a note to our clinical nurses saying, for example, ‘This patient is high-risk and starting a new medication.  Let’s place them on the high-risk list and follow up via phone in 3-6 weeks, with our nurse coordinator or our pharmacist, to see how they are doing.”
2. Define inclusion criteria

Defining inclusion criteria can help you identify those patients at highest risk of being hospitalized or going to the emergency room. 

  • Tip 1: Select the inclusion criteria that you feel adequately captures those patients at highest risk. The most common criteria that clinics used included those patients who were:
    • Actively flaring
    • Recently hospitalized or visited the emergency room
    • On corticosteroids
    • Starting a biologic
    • Frequently calling or visiting the office
    • Experiencing psychosocial issues (ex. depression/anxiety)
    • Not adhering to the treatment plan (ex. non-adherence to medication)
    • Not confident in their ability to manage their symptoms
    • Pregnant
  • Tip 2: If the chosen inclusion criteria are capturing too many patients for you to effectively manage, re-examine and remove some criteria. Several clinics chose to do this along the way.
  • Tip 3: If the inclusion criteria are not adequately capturing the highest risk patients, use your intuition and ask yourself: “Which patients are keeping me up at night? Which patients am I most worried about? For which patients can I make the most difference?” Then, work with those patients.

Examples: 

NYU Langone - “In the beginning, we tried to be more structured (with our high-risk inclusion criteria). For example, starting a new biologic or those patients we see in high volume. Ultimately, it came down to, ‘Who am I worried about, and who keeps me up at night?’ It could be someone going to the hospital, someone that is actively flaring and has poor follow-up, or somebody with depression or anxiety issues.”
Spectrum Health - “My criteria are based on how the patient has done in the recent past, such as recent hospitalizations, complications, new diagnosis of severe disease, etc. There were people who had medically severe disease but weren’t on the high-risk list because they didn’t need much handholding from us. For example, some people are very in-control even though they have severe disease – and I know that they will be proactive in reaching out to me. So, I give those patients the responsibility of reaching out to me and say, ‘Hey, reach out to me in two weeks and let me know how things are.’  The patients who are more overwhelmed are the patients that I will send to my nurses for further follow-up.”
3. Set a manageable number of high-risk patients

In an ideal world with unlimited resources, we could offer urgent care services to every high-risk patient. However, most clinics do not have the capacity to provide heightened surveillance to everyone. Therefore, it is important that you establish a maximum number of high-risk patients that your clinic staff can manage successfully – otherwise you may be setting yourself, your colleagues, and your patients up for disappointment.

  • Tip 1: Start off small. While the number of high-risk patients each clinic could manage successfully varied, the majority had the greatest success when they kept the high-risk list between 5 to 10 patients. 
  • Tip 2: Monitor the number of patients on your high-risk list regularly and adjust accordingly. Routinely check-in with the person managing the high-risk list to ensure you are successfully managing your high-risk patients. If you find that you do not have enough resources, reduce the number of patients on the high-risk list and focus on those at highest risk. If you have enough resources, increase the number.

Examples: 

Gastroenterology Associates, Inc. - “We found that having a big list was not practical. We wanted to identify the patients that we were most worried about, in terms of ending up in the emergency room or requiring urgent care. Therefore, we selected a ‘Top 5-7 List.’ Specifically, these were patients who: were flaring and on steroids, had recently been in the hospital or emergency room, or recently started a biologic. Our medium-risk list were patients teetering on the edge, but not enough to be on the ‘Top List.’ For example, these were patients who had problems with insurance, getting rides, understanding the importance of not missing their medications, etc. We thought it would be helpful to keep track of these medium-risk patients, and follow-up with them every few months, rather than weekly, like we would with the Top List.”
Cedars-Sinai Medical Center - “Limiting the high-risk list to 10 patients was the most manageable choice for us. We wanted to specify the highest of the high-risk patients and focus our resources on them.”
4. Define removal criteria

Without defining criteria for removing patients from the high-risk list, your list may start accumulating names and growing exponentially.  Several clinics sought to avoid this situation by designing removal criteria they felt were most appropriate for them as well as their high-risk patients.

  • Tip 1: Work with your colleagues to establish removal criteria that everyone is comfortable with.
  • Tip 2: Be flexible. Not every patient’s reason for being on the high-risk is the same. Therefore, you may need to have different removal criteria for different situations.
  • Tip 3: Create a workflow/process for removing patients from the high-risk list, including who is responsible for making the decision to remove someone as well as who is responsible for physically removing them. For most clinics, the nurse responsible for physically adding patients to the high-risk list was also the person responsible for physically removing them.

Examples: 

MedStar Health - “Some people were on the high-risk list because they were non-adherent – and, when they started coming in regularly to get their treatments, they would come off the list. If the patient was coming in for a lot of emergency room or urgent care visits – once their disease was in remission, they would come off the list. It was dependent on why they were on the list in the first place. On the high-risk list we did have a column labeled, ‘reason for high-risk.’ Having the reasons listed was important for getting someone off the list.”
Regional Gastroenterology - “They stay on the high-risk list until their next visit.  Upon their next visit, we use the same questions and physician assessment. If the physician marks them as no longer high-risk, then the nurse takes them off the list.”

Resources:

 

This project is supported by a grant from The Leona M. and Harry B. Helmsley Charitable Trust.

 

Helmsley

 

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