Advanced Illness Management

Advanced illness management programs, such as specialty home-based palliative care, are finally getting recognition for their ability to achieve the Triple Aim. However, success in emerging value-based contracts is dependent on the ability to identify the patients most likely to benefit, careful monitoring of progress, and the ability to measure clinical and financial impact.

Cyft Models Are Unlike Off-The-Shelf Risk Scores That Find the Highest Utilizers

  • Designed by our in-house palliative care and data science experts
  • Use AI and all available data including notes and social determinants
  • Deliver rank-ordered lists of patients most likely to benefit from palliative care and hospice
  • Consider the likelihood of impending ED visits and inpatient admissions
  • Keep improving with new experience and routinely refreshed data

Progress Reports Track Activity and Promote Continuous Improvement

Outcomes and Utilization:

  • Inpatient admission and ED visit rates
  • Total end-of-life spending
  • Hospice enrollment and length of stay
  • Goal-concordant care
  • Patient-reported outcomes

Process Measures:

  • Symptom assessment, management, and treatment
  • Goals of care, values, and preferences documentation
  • Documentation of surrogate
Sample Palliative Care Report Page 1

Know the ROI of Your Program

The ability to demonstrate the value of your program is critical to long term success. Cyft helps quantify the impact in terms of utilization and cost reduction compared to a rigorously-defined control group.

Learn how we partner closely with our customers to move the needle on advanced illness management.

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