The Challenge
In Chicago, more than 65% of premature mortality is tied to social determinants of health (SDOH). From environmental factors (lead exposure) to low-income access challenges (lack of transportation and high rent), Chicagoans struggle to access the care they need during critical health moments.
The University of Chicago Medicine (UChicago), a not-for-profit academic health system formed in 1927, recognized the need to proactively address SDOH barriers after noticing stark gaps in care. To allocate resources for SDOH patients, UChicago first needed to gain a better view of which patients were at risk. UChicago collaborated with Bamboo Health to achieve this goal of expanding value-based care outcomes for vulnerable patients, including reducing costs through identifying potential high-utilizers of costly care.
Before implementing Bamboo Health’s Rising Risk solution, UChicago faced challenges in identifying and tracking patients at risk of becoming high utilizers of medical services, such as frequent emergency department (ED) visits amid a sea of SDOH barriers. The primary challenge was the need for a streamlined and automated process for monitoring rising and high-risk patients. Care coordinators at UChicago had to rely on custom filters within their patient management system or claims data, which is often 60 to 90 days lagged. This manual process often led to missing these rising or high-risk patients due to unavailable and/or obsolete data or lack of visibility into patients seen by an out-of-network primary care provider. As a result, some patients received care from costly healthcare settings like the ED.
The Solution
UChicago adopted Bamboo Health’s Rising Risk solution to enhance its patient identification and tracking process. Rising Risk, part of Bamboo Health’s Pings suite, offers multiple tailored solutions based on Pings admission, discharge and transfer (ADT) insights, providing real-time insights on patients at risk of high utilization of healthcare resources and eliminating the need for manual custom filters. With Rising Risk, care coordinators at UChicago can efficiently monitor patients, identify those needing care coordination and intervene in real time.
“The availability of real-time data directly in our workflow helps eliminate a lot of extra work. It also allows us to catch patients while they’re currently in care, making it easier to build rapport to ensure follow-up and improved care quality.”
Kate Sullivan Project Manager at UChicago
The Results
Rising Risk Further Helps UChicago to Achieve:
- Improved Patient Identification of At-Risk Patients: Rising Risk provides a condensed list of potential high-risk patients before they become high utilizers of the medical system. This makes it easier for UChicago to identify and monitor patients in real time.
- Timely Intervention for Improved Outcomes: Real-time insights enable care coordinators to intervene while patients are still in the hospital or soon after their visit with the SMS contact-sharing feature, allowing the option to connect to follow-up care such as skilled nursing facilities.
- Enhanced Patient Engagement: Patients are more likely to be involved when care coordinators can establish a timely relationship with them and connect them to the appropriate longitudinal care. UChicago’s recapture rate significantly increased after implementation, seeing how quick outreach made patients more willing to continue the momentum.
- Effective Patient Tracking: Rising Risk ensures that patients are noticed, even when primary care providers are unavailable or out-of network, a traditionally laborious or complex process. With targeted post-discharge follow-up, patients have the opportunity to enroll in care management programs.
- Advanced Analytics and Data Access: When UChicago adopted Rising Risk, it gained access to nationwide ADT data through the most powerful care coordination network in the U.S., allowing the organization to leverage real-time ADT data combined with predictive analytics and machine learning to identify and track patients throughout their care journeys.
- Optimized Workflows: UChicago directly manages patient prioritization and post-discharge follow-up in its electronic health record. The simplified workflow allows for even greater efficiency during follow-up.
The Impact
At the end of 2023, a patient (who we will refer to as John) had a chronic condition. When John experienced pain or needed support, he visited the ED. While the ED could support John in the short term, he was in desperate need of longitudinal care to manage his chronic condition after three ED visits in three months. Care coordinators at UChicago received an alert via Rising Risk that John appeared at the ED more frequently than other patients. This alert helped coordinators connect John to the care he needed, ultimately referring him to a skilled nursing facility and arranging follow-up appointments to support him with his chronic condition. With Rising Risk’s patient identification support, UChicago Medicine managed these additional appointments and brought him back into care with his primary doctor at UChicago post-discharge.
“It’s so helpful for us to see where patients are having external utilization troubles that typically we couldn’t catch. It’s amazing to pull people back into our network and connect them to the care they need.”
– Kate Sullivan, Project Manager at UChicago
In addition, UChicago uses Rising Risk to identify patients who may need support due to SDOH. Another patient (who we will refer to as Kelly) arrived at her primary care provider reporting physical health concerns. After the Rising Risk tool’s predictive analysis determined risk (based on data around hospital utilization, demographics, geographic location, diagnosis history and insurance), care coordinators received a Ping in the Rising Risk platform that Kelly had barriers to care that would prevent timely follow-up, including the need for transportation. UChicago’s care coordinators were able to arrange transportation to help Kelly get to and from her necessary medical appointments. As a result, Kelly could easily access her follow-up appointments and get the essential care that would have otherwise been postponed or avoided altogether. Numerous UChicago patients have been identified and brought into follow-up care under similar circumstances.
The implementation of Bamboo Health’s Rising Risk solution has significantly influenced UChicago Medicine’s care coordination efforts, including:
patients identified in the first year of implementation, who otherwise would’ve fallen through the cracks
patients referred to UChicago’s Ambulatory Care Coordination Team for follow-up
minutes on average saved in reviewing patients’ charts
average hours saved in chart reviews
How Rising Risk Works for UChicago Medicine
About the University of Chicago Medicine
University of Chicago Medicine (UChicago Medicine) is a not-for-profit academic health system formed in 1927. Based on the campus of the University of Chicago Medical Center in Hyde Park, and with hospitals, outpatient clinics and physician practices throughout Chicago and its suburbs, UChicago unites five organizations: Pritzker School of Medicine, Biological Sciences Division, Medical Center, Community Health and Hospital Division, and UChicago Medicine Physicians.
About Bamboo Health
Bamboo Health empowers healthcare organizations to improve behavioral and physical health outcomes through the most powerful care collaboration network with Real-Time Care Intelligence™. By providing real-time insights during pivotal care moments, clients are enabled to perform life-improving actions and deliver seamless, high-quality and cost-effective whole-person healthcare. From coast to coast, Bamboo Health partners with five of the six major pharmacy chains, 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually.
