5 steps to align Risk and Quality for better health outcomes

Risk Adjustment and Quality Improvement teams often find themselves in an awkward dance, approaching the same providers to request the same medical records about the same patients over and over again. Risk and Quality teams have different missions, but they both play a role in improving the cost and quality of care for patients—and largely rely on the same data to reach their objectives. This redundancy often frustrates everyone involved: providers, members, and health plans. Mixed messages and overlapping outreach create inefficient processes, provider abrasion, fragmented member experiences, and wasted resources.

There is a better way, but it requires collaboration, shared data and technology. This week Elissa Toder, Reveleer Vice President, Quality Improvement Strategy and Solutions, presented at the RISE STAR Rating Masterclass on how to better align Risk and Quality functions. Here are the five steps she shared to a more cohesive approach:

1. Build organizational bridges

The organizational change needed to align Risk and Quality requires buy-in from senior executives and their teams. Functional leaders will need to break down silos and drive organization-wide collaboration and accountability. A joint-steering committee should align cross-functional communications to maintain consistent messaging.

2. Share and enrich patient data across Risk and Quality teams

For Risk and Quality teams to really accelerate their respective audits, they need to work from shared data, a centralized patient data repository continually enriched with new information from various sources, including claims, lab results, and patient charts. A unified view allows both Risk and Quality teams to access a complete patient profile and reduces duplicate provider requests. Having records available for both teams also shortens retrieval turnaround times and accelerates coding and abstraction. As part of building a unified view of patient data, teams will need to implement robust data governance practices to ensure data accuracy, compliance, timeliness, and consistency across all systems.

3. Streamline provider and member communication

Risk and Quality teams should create a unified outreach strategy with a comprehensive "gap in care" suspecting list that gives providers a longitudinal view of each patient, including all needed care and documentation requirements. This approach allows providers to address multiple issues during a single visit, improving efficiency and patient care.

For member communication, coordinate efforts across all departments to ensure consistent messaging. Create an inventory of all touchpoints with members and providers to understand the cadence of outreach and avoid overwhelming them with redundant information. Consider implementing a "provider team" approach, where both Risk and Quality representatives are assigned to specific providers and collect information or deliver updates on behalf of both teams. ‍

4. Implement year-round engagement strategies

When Risk and Quality teams share data, they have a better chance to identify high-priority patients early and engage them throughout the year. Year-round strategies allow data collection to start earlier in the year, helping to identify at-risk members sooner to support proactive provider and member communication objectives. Provider relations teams can also distribute current year data to doctors, even during traditionally busy periods like HEDIS kickoff.

Proactive outreach requires continuous chart retrieval that supports both Risk and Quality needs. When collecting charts for one purpose (e.g., HEDIS), retrieval teams can gather as much current year data as possible to support prospective risk programs and year-round quality initiatives. The goal is to eliminate retrospective work as much as possible by accessing claims and visit data immediately after encounters for prompt coding.

5. Explore platforms and solutions that support Risk and Quality

The industry has discussed the benefits of aligning Risk Adjustment and Quality Improvement for years, but data silos and technology limitations have held back real progress. Advances in AI and SaaS platforms have led to comprehensive solutions that support end-to-end workflows from outreach and retrieval through coding and abstraction. Centralized patient record systems enable easier data integration between Risk and Quality teams, as well as quick access to historical records, reducing the need for repeated chart requests.

With the advancements in artificial intelligence, these new solutions can scale clinical data ingestion and review, pinpointing relevant information and linking that to source documents. With an AI assistant, coders and abstractors can accelerate clinical review, especially when working with large charts and unstructured data.  This technology shifts the focus to analysis and intervention instead of data entry.

With these new solutions, risk and quality teams can now manage projects, aggregate data, and provide feedback to providers with enhanced analytics and dashboards. By implementing these strategies, Risk and Quality leaders can transform their approach to healthcare management. This alignment not only improves operational efficiency but also enhances provider relationships and ultimately leads to better patient outcomes.