Flagging Fragmented Care – Risk Stratification Analytics Part 9

Flagging Fragmented Care – Risk Stratification Analytics Part 9

We all know health care is fragmented, especially for those with higher medical needs. When you are trying to control costs and improve the health of your patients, you need the right information to understand who needs your services the most. It’s not enough to just focus on patients with a certain condition or rely on patients that have preventative screening gaps. You are trying to impact patient lives, and that means you need patient-centered analytics like coordination markers.

Why It’s Time to Start Focusing on Coordination Risk

Today, high quality health care depends on care coordination. Consider the many different settings that health care consumers can seek out care. How well you and the extended care team interact together with a patient determines what kind of health outcomes that are achieved. Patients that receive poorly coordinated care are at higher risk for worse health outcomes and higher medical expenses, than those individuals that receive coordinated care. And that is why it’s imperative to identify these patients that are at higher risk of receiving uncoordinated health care early. However, it’s not always that easy as it takes time and effort to dig through charts and call other providers to piece together the full story. Leveraging interoperability technology, like KPI Ninja’s, with advanced analytics like the Johns Hopkins ACG® System, cuts through the complexities to save you time and help you get back to treating patients. Here are a few examples of coordination flags that help you gain a more holistic perspective of a patient’s risk for fragmented care.

  • Unique Provider Count: The number of unique providers that have delivered care to the patient.
  • Specialty Count: The number of unique specialty types that have provided care to the patient.
  • Management Visit Count: The total number of visits across all providers.
  • Generalist Visit Count: The total number of visits with a generalist (primary care).
  • Majority Source of Care: The percentage of visits that were completed by the provider that rendered the most care to the patient.

Calculation of these markers permit both patient and population-level insights, like the Care Management report and the Unique Provider Count graph that are shared below.

care management report
unique provider count graph

Providing technology solutions that help tackle health care fragmentation and give every clinician the information they need to make meaningful change is the centerpiece of our mission here at KPI Ninja. For health care organizations, analytics like the ACG System’s coordination markers that are built on KPI Ninja’s interoperability technology will mean less time in front of a computer, and more time improving and delivering care with great coordination and impact.


Renee Towne

About the Author
Renee Towne
Director of Quality Programs at KPI Ninja, Inc.
Renee provides operational leadership of quality initiatives at KPI Ninja. Towne has a background in occupational therapy, education and experience in operational excellence across a variety of healthcare domains. Based on prior experience as a clinician that drove outcomes patient by patient, she is leaving a larger footprint by improving health care more comprehensively, population by population.


About KPI Ninja
KPI Ninja is a data analytics company that helps healthcare organizations accelerate their quality, safety, and financial goals with a unique combination of software and service. We are differentiated by our signature mix of technology, performance management consulting and healthcare expertise. We don’t merely offer software solutions but work shoulder to shoulder with clients to help them draw on the power of analytics and continuous improvement methodologies to become more efficient. In harmony with our data-centered ethos, we truly believe that our success is strongly co-related with yours.

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