Rising Risk: The Preventive Advantage
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The Window Before the Storm:
Why Catching Rising Risk Is the New Frontier in Value-Based Care
There’s a moment in every patient’s health journey when things start to shift—but before everything unravels. It’s subtle. A slight change in lab values. Missed appointments. Early signs of medication nonadherence. These aren’t red flags yet—but they’re not green lights either. It’s a space we call rising risk, and for Accountable Care Organizations (ACOs), Managed Care Organizations (MCOs), and value-based care leaders, it’s where the real opportunity to bend the cost curve lies.
The Flawed Focus on High-Risk Patients
High-risk patients—the ones cycling in and out of the ER, with advanced chronic conditions and complex comorbidities—get a lot of attention. And rightly so. But focusing only on those patients is like putting a bucket under a leak instead of fixing the roof.
By the time a patient is categorized as “high-risk,” the damage is often done. Costs have skyrocketed, outcomes have worsened, and interventions are more reactive than strategic.
The better bet? Spot the storm forming—and act before it hits.
What Is Rising Risk—And Why Should You Care?
Rising-risk patients are those whose clinical, behavioral, or social data suggests a trajectory toward poor health outcomes, even if they’re currently “stable.” They aren’t just a ticking time bomb; they’re a warning light. And ignoring them means lost time, missed opportunity, and increased costs down the line.
Studies show that a significant portion of healthcare spend is driven by this group—not the high-risk cohort. They’re the 55-year-old with gradually worsening A1c levels, the recently discharged CHF patient skipping follow-ups, the caregiver-dependent senior whose early signs of cognitive decline are going unnoticed.
Why Traditional Risk Models Miss the Mark
Most risk stratification tools are built to flag high-risk patients, not forecast who’s heading there. They rely heavily on retrospective claims data, which paints an incomplete—and often outdated—picture. These tools are reactive, not predictive. And predictive alone isn’t enough either.
What’s missing? Actionability.
That’s where OptMyCare comes in.
The OptMyCare Difference: Predictive + Prescriptive
OptMyCare doesn’t just highlight rising risk. We translate it into suggested action—right-sized for your care team, customizable to your population, and prioritized based on real-world impact.
Here’s how it works:
- Clinically engineered algorithms pull from multiple data streams: clinical, claims, social determinants, and patient-reported insights.
- Rising-risk trajectories are modeled in real-time—not after the fact.
- Suggested care interventions are generated for each patient: a nurse check-in, a medication review, a behavioral health referral, or enrollment into care management.
It’s not just “this patient may escalate.” It’s “here’s what to do right now to prevent that escalation.”
A Tale of Two Trajectories
Let’s meet two patients.
Patient A: Mrs. Rivera
65 years old. History of hypertension, borderline diabetes, and arthritis. No hospitalizations yet, but her BP readings have crept up over the past 90 days, and she missed her last follow-up.
OptMyCare flagged her as rising-risk and recommended a care manager outreach. During that call, it was discovered she had recently lost her spouse and was struggling with transportation. Social services were engaged, her PCP visit was rescheduled, and a nutritionist was looped in.
She never became high-risk.
Patient B: Mr. Lee
Same age. Similar history. No outreach. Within two months, he landed in the ED with uncontrolled blood pressure and shortness of breath. Diagnosed with CHF. Now categorized as high-risk, on multiple medications, and requires intensive ongoing management.
The difference? Timing and action.
Rising Risk Is the Next Competitive Advantage
In a landscape where margins are tight, compliance is complex, and workforce shortages are real, ACOs and MCOs need smarter ways to prioritize. Rising-risk management isn’t just a clinical strategy—it’s a financial one.
- – Reduce avoidable utilization before it starts.
- – Prioritize care coordination where it matters most.
- – Deploy stretched teams with laser-like precision.
Why This Matters Now
CMS continues to signal its commitment to outcomes over volume. Quality measures, shared savings, and performance benchmarks are increasingly tied to how well you prevent deterioration—not just how you respond to it.
If your organization waits until a patient becomes high-risk to intervene, you’re playing catch-up in a game that rewards foresight.
Where OptMyCare Fits In
We were built for this moment.
OptMyCare’s platform is clinically informed and operationally efficient. We deliver not just predictive insights, but actionable next steps and even provide RN-led care management support when your team is stretched too thin.
You’ll know who’s at risk. You’ll know what to do. And if needed, we can help get it done.
Ready to Get Ahead of the Curve?
The storm doesn’t have to hit. With the right insights—and the right partner—you can stop it before it starts.
Let’s talk about how OptMyCare can help you take rising-risk management from buzzword to core strategy.
