Predictive Analytics — ACO / Value‑Based Care
Patient: Ken Mathew · Age 41 · Gender: Male · Member ID: 222‑222‑2221 · Last sync:
Hospitalization Risk (24 mo)
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CImodel 95%:
Mortality Risk (24 mo)
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CImodel 95%:
30‑Day Readmission Risk
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Recent DC events: none in last 12 mo
Adherence Signal (meds & pathways)
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Proxy: timely refills, app task completion
Risk Gauges
High
Elevated
Lower
Top Risk Drivers
What‑If Simulator
Adjust levers to see projected impact over 24 monthsTip: Try reducing BMI by 5 points and SBP by 10 mmHg to preview potential reductions in hospitalization risk.
Patient Feature Snapshot (from EHR & App)
Last EHR pull: 2025‑02‑12| Feature | Patient Value | Reference / Goal | Risk Signal |
|---|---|---|---|
| Age | 41 years | — | Low impact |
| Body Mass Index | 43.8 | < 30 | Severe obesity |
| Blood Pressure (avg) | 148/88 mmHg | < 130/80 | Stage 2 HTN |
| HbA1c | 5.8% | ≤ 5.6% (no DM) / < 7% (DM) | Prediabetes/controlled T2DM |
| Lipids | TC 190 mg/dL (LDL <100, HDL >40) | LDL <100; HDL >40 | At goal on statin |
| Chronic Conditions | T2DM (no complications), HTN, Hyperlipidemia, Class III obesity | — | Multi‑morbidity |
| Medications | Metformin; Semaglutide (Ozempic); Tirzepatide (Mounjaro); Losartan; Pravastatin; MV; Loratadine | — | Cardiometabolic therapy |
| Adherence proxy | Recent timely refills; active app use | ≥85% | Protective |
| Immunizations | COVID up to date; Influenza 2025; PCV13 2022; Tdap 2013 | Flu annually; Tdap q10y | Due Tdap in 2025 |
| Recent Encounters | Office visits 01/2025; refills 02/2025; no inpatient stays in 12 mo | — | Outpatient only |
| Allergies | Penicillins (rash), Midazolam (intolerance) | — | Profiled |
| Vitamin D | 25 ng/mL | 30–100 ng/mL | Low |
Care Gaps & Next Best Actions
Prioritized by expected risk reduction- ✓ Continue GLP‑1 therapy; reinforce lifestyle coaching — projected ↓ hospitalization risk 1.2–2.0 pts at 24 mo.
- ⚠ Optimize HTN control (target SBP <130): add titration/home BP pathway — projected ↓ 2.5–3.5 pts.
- ⚠ Weight management pathway (–5 BMI points): projected ↓ 3–5 pts hospitalization, ↓ 0.4–0.8 pts mortality.
- ⚠ Tdap booster due (last 2013) — close preventive gap this quarter.
- ◻ Address low Vitamin D (per PCP) if clinically indicated.
Model Transparency (Demo)
This screen uses a demonstration logistic model to estimate 24‑month hospitalization and mortality probabilities from structured features (age, BMI, BP, HbA1c, chronic conditions, prior utilization, adherence proxy). Coefficients are heuristic and not derived from a real patient‑level claims dataset. Do not use for clinical decisions. In a production ACO deployment, Calcium would train & validate models on de‑identified, IRB‑approved data; include bias & calibration reports; and enable site‑level recalibration.