By Jon Phillips, Chief Analytics Officer

An important part of Millennium’s mission is to help connect Medicaid members to primary care providers so they can consult with their physician at least one time per year.

There is clear medical evidence that there are health benefits to an annual primary care visit. Early identification of health risks and patient engagement in self-care are critical factors in keeping people well and better managing chronic conditions.

How will Cerner HealtheIntent and our Data Analytics team help us achieve this goal?

First, we are compiling the most comprehensive patient record in Western New York through our population health management platform.  With this information, we are identifying who is seeing their primary care provider at least once per year and who is not.  We are generating patient lists to identify whether a Medicaid member has an assigned primary care provider and who they have seen most often and most recently.  Lists are generated for practices who have attributed patients that have not had a primary care appointment in the last year.  If there is not a primary care provider, there will be outreach directly to patients to identify a primary care provider that is convenient for the patient to visit, understanding such factors as transportation concerns.

All too often, we are finding patients whose only healthcare encounters are in local hospitals.   We are also identifying these patients for outreach and engagement with a primary care provider as well as identifying any social determinants of health that may be causing preventable high cost utilization of hospital services.

Millennium is generating performance reports and actionable patient lists for our partners to help them better assist high risk patients and ensure that low risk patients have their diseases well managed by:

  • Stratifying patients by hospitalization encounters, potentially preventable visits, potentially preventable readmissions.
  • Utilizing pharmaceutical claims to understand medication adherence and identify potentially high-risk medication combinations.
  • Alerts for patients who are initially flagged as high risk and potentially the most immediate need for care coordination.

For further information, please contact me at jphillips1@millenniumcc.org

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