Posted by Prealize Health ● June 10, 2021

How Prealize Health is Helping Sentara Health Plans Improve Care Management, HEDIS, and Star Ratings

Sentara Heath Plans, the health insurance division of Sentara Healthcare, serves over 875,000 members in Virginia through its subsidiaries, Optima Health and Virginia Premier. While the company has several highly successful and rapidly growing health plans, about two years ago it recognized that it needed a better approach to predict rising risk and manage members’ care and costs. 


“If you took a population of our size and told us to select the top 2,500 high risk members whose healthcare costs were going to increase, we would have been right about 5% of the time,” said John Coughlin, Vice President of Information and Analytics at Optima Health (Sentara Health Plans), during a recent panel discussion with Prealize Health. That spurred the health plan to look for a partner that could significantly boost its forecasting abilities.


“The industry has been waiting for the right tools to help us get better at predicting rising risk. The tools are finally catching up to what we need.”

- Thomas Lundquist, MD, CMO, Sentara Health Plans


After testing various tools in the market, the organization selected Prealize Health, a predictive analytics platform fueled by machine learning. Prealize’s analytics tools provide highly accurate insights as a result of training the predictive models on Sentara Health Plan's data sets versus nationally available data. 


“We selected Prealize after testing its models and finding that they accurately predicted which members would become high cost 55% to 64% of the time,” said Coughlin. “Other tools we considered were successful only 17% to 36% of the time. We were really confident that with Prealize we were going to be able to identify the right members to reach out to.” 


Meaningful health improvements and a more positive member experience 


While accurately predicting risk is an important first step for health plans, they must then connect with and engage those high-risk members. Here too Prealize is helping Sentara Health Plans—by providing prioritized member lists, case summaries, and action plans for high-risk members, said Kia Dunbar-Harris, Vice President of Clinical Care Services at Optima Health (Sentara Health Plans). 


“We've been able not only to stratify our members into appropriate risk categories, but also to identify the level of touchpoints that each new member might need.”

- Kia Dunbar-Harris, VP of Clinical Care Services, Optima Health (Sentara Health Plans)


This is leading to a significant increase in member engagement, as well as a decline in high-cost healthcare utilization. In fact, since implementing Prealize, Sentara Health Plans has experienced a 19% increase in member engagement, a 9% decrease in emergency room utilization, and 7% decrease in inpatient cases for members. 


“Having predictive analytics is helping us build trusting relationships with our members very early on, which definitely increases and improves member engagement and the member experience,” said Dunbar-Harris. “That’s important for our Medicare plans and our NCQA accreditation that focuses on Star Ratings and HEDIS scores.” 


Four Keys to Success


Dunbar-Harris identified four components of the Prealize solution that are key to the improved member outcomes, engagement, and experience. 


1. Personalized outreach  

As noted, Prealize provides prioritized member lists, case summaries, and action plans for each member, which reduces staff time sifting through EHR data, and helps the care management team understand each individual’s needs more quickly.

Dunbar-Harris explained, “Having the information readily available from Prealize allows our clinical teams to shift from a reactive, one-size-fits-all model to more proactive and individualized models of care. It enables us to be sensitive to members’ unique needs while reaching, educating, and empowering them, which has been very meaningful to our case management program.”


2. Enhancing collaboration with providers


Prealize is helping Sentara Health Plans improve relationships with its provider partners, which helps boost member engagement and health, said Dunbar-Harris. “We've been able to leverage our Prealize data to be more collaborative with our providers in the community. That often goes a long way in encouraging our members to participate in our programs and helps us create a better member experience.” 


3. Maximizing care management resources and supporting growth 


While growth is the goal of most health plans, it can be challenging to quickly identify and meet the needs of new members. Prealize enables Sentara Health Plans to maximize its resources by identifying the members most in need of proactive outreach. “We need to be able to address the needs of our members quickly as we continue to grow,” noted Dunbar-Harris. “We've been able not only to stratify our members into appropriate risk categories, but also to identify the level of touchpoints that each new member might need.”


For example, members who manage their chronic illness very well may still need to receive periodic educational materials and other information. More complex members may need direct telephonic case management, said Dunbar-Harris. “The tool has helped us to identify how we can separate those groups of members and intervene appropriately and quickly.”  


4. Identifying social determinant of health-related interventions 


As health plans increasingly recognize the need to address social determinants of health, data and insights, like those that Prealize provides, is critical. “We can help patients coordinate appropriate community resources and services,” said Dunbar-Harris. “Being able to have that real-time information as opposed to waiting for a claim flag that comes in sometimes as much as six months after the fact empowers the team to have meaningful conversation and engagement.”