MMHA 6520 Week 11 Population Analytics Proposal Example

Reaching Members Within Days of Discharge: A Population Analytics Proposal for Riverline Health Plan

Student Name

Walden University

MMHA 6520: Health Informatics and Population Health Analytics

Instructor Name

Month Day, Year

Reaching Members Within Days of Discharge: A Population Analytics Proposal for Riverline Health Plan

Executive Summary

Riverline Health Plan, a Medicaid plan built for this course, learns of most members' hospital discharges from claims that arrive weeks later, after the period when follow-up matters most. Exchange notices of those same discharges already reach the plan on the day they happen, but they wait in an inbox and are acted on only for members already in care management. This proposal requests approval and funding to route those notifications to a transitions team that calls eligible members within two business days and asks their assigned practices to see them within seven days. It covers adults going home from an inpatient stay whose primary care is attributed to a network practice. The expected near-term result is a higher share of members seen in primary care within seven days of discharge; effects on readmission and emergency use will be measured but may take longer to appear. The rollout is staggered across practices so that the effect can be measured. Leadership is asked to decide by the end of next month so that the first practices can begin in the following quarter.

Population

Eligible members are working-age adults leaving a hospital ward whose attributed primary care home, on the day they go home, is one of Riverline's network practices. Table 1 states the inclusion rules, which follow the assignment-based definition adopted in the plan's earlier denominator work.

Table 1

Population Definition

Note. Continuous enrollment is not required, because members with interrupted coverage are among those most likely to need help after discharge.

Data Sources

The proposal relies on three sources, chosen for speed where speed matters and completeness where it does not. Hospitals participating in Medicare are required to send admission and discharge notifications electronically (42 C.F.R. § 482.24), which makes the exchange the fastest source. Table 2 lists each source.

Table 2

Data Sources, Delays and Owners

Note. Claims are not used to trigger outreach, because they arrive too late for the purpose.

Segments and Workflow

Not every discharged member needs the same response. Table 3 applies the plan's revised risk segments to the discharge population.

Table 3

Segments and Outreach After Discharge

The workflow is simple. A notification arrives, is matched and checked for eligibility, and enters the transitions team's queue with its segment flag. A coordinator calls, confirms the member has medications and understands instructions, asks about barriers and records the result. The assigned practice receives a secure notice the same day with a request for a seven-day visit. Structured follow-up of this kind is a component of discharge programs shown to reduce return visits (Jack et al., 2009).

Data Sharing

Notices to practices will contain only the member's name, date of birth, discharge date, hospital and primary discharge diagnosis. Disclosures to treating practices are permitted under HIPAA (45 C.F.R. § 164.506). Social needs screening answers will not be shared with practices or community partners through this workflow; referrals to community resources will follow the plan's consent-based process, sharing a minimum field set with the member's agreement.

Measurement

The rollout will be staggered: network practices will be placed in random order into four waves, starting two months apart, letting the practices still waiting act as the yardstick for those already running the workflow (Hemming et al., 2015). This design avoids the before-and-after comparison that overstated the effect of the plan's high-utilizer program, where members selected at a peak of use would have used less afterward regardless (Barnett et al., 2005). Table 4 summarizes the plan.

Table 4

Measurement Plan

Note. Members who lose coverage remain in the analysis using enrollment files, so results are not inflated by attrition.

Staffing and Cost

Table 5 lists staffing by role. Costs will be presented by the finance team using the plan's salary scales; this proposal does not estimate dollar amounts.

Table 5

Staffing by Role

Oversight

Day-to-day responsibility for the workflow sits with the care management director, who will report monthly to the quality committee on reach and response times. The informatics director will own data routing and the evaluation analysis. The privacy officer will review data sharing terms before launch. At month 12, the quality committee will receive the evaluation and advise leadership on the program's future, including whether to widen it to members outside network practices.

What This Design Cannot Show

The design will show whether calling members and alerting practices increases seven-day follow-up visits. It may not show an effect on readmissions or emergency use within the first year, because those outcomes are less frequent and influenced by many factors beyond follow-up visits. A null result on readmission in year one would not mean the program failed. The design also cannot show effects for members not assigned to a network practice, who are excluded, or for discharges from hospitals that do not send notifications. Finally, it measures what happens when the plan acts on notifications; it does not measure the value of the exchange connection itself.

Schedule

Months 1 and 2: build routing, notices and the transitions queue; hire or assign coordinators. Month 3: the first quarter of network practices goes live. Months 5, 7 and 9: the remaining three waves follow. Month 12: evaluation report to the quality committee. Leadership approval by the end of next month keeps the first wave on schedule.

References

Barnett, A. G., van der Pols, J. C., & Dobson, A. J. (2005). Regression to the mean: What it is and how to deal with it. International Journal of Epidemiology, 34(1), 215-220. https://doi.org/10.1093/ije/dyh299

Condition of participation: Medical record services, 42 C.F.R. § 482.24 (2024).

Hemming, K., Haines, T. P., Chilton, P. J., Girling, A. J., & Lilford, R. J. (2015). The stepped wedge cluster randomised trial: Rationale, design, analysis, and reporting. BMJ, 350, Article h391. https://doi.org/10.1136/bmj.h391

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007

Uses and disclosures to carry out treatment, payment, or health care operations, 45 C.F.R. § 164.506 (2024).