Effective care management is essential for reducing unnecessary healthcare utilization, improving clinical outcomes, enhancing quality of life, and controlling costs. However, care management teams at healthcare payers often struggle with siloed data, fragmented care plans, and a lack of a standardized methodology to identify at-risk members and intervene effectively.

Fractal Health Triage (“Triage”) is a solution for payers that provides a comprehensive view of the member, enabling care managers to identify and prioritize high-risk individuals who would benefit most from 1:1 engagement with the care team. The solution recommends personalized care plans for members to improve their health outcomes while driving cost efficiency. Additionally, it includes GenAI-powered decision intelligence to help answer key business questions.

Triage follows a multi-step process:

1. Segment the population into risk cohorts based on their health profile.
2. AI models, clinical triggers, and data triggers help identify at-risk members, including inpatient admission, readmission, and high-cost members.
3. Gaps in care are identified through clinical systems for shortlisted at-risk members. The at-risk members are prioritized based on impactability, likelihood of engagement, and severity of their health risk. The top n% prioritized members make it to the “needs intervention” bucket.
4. Additional information is added to the “needs intervention” list, including personal preferences, personalized care plans, channel preferences, social determinants, and digital engagement, etc.
5. The Next Best Action model recommends personalized care plans for members based on their medical history and lifestyle behaviors.
6. Triage can be integrated with the payer’s existing care management platform, where the “needs intervention” group is assigned to care managers with all the intelligence needed to help them interact with members and manage/mitigate their health risk.
7. Feedback from members and the care management team is captured through the care management platform and used to improve intervention strategies over time.