1. Risk Stratification for Care Management
Transforming Clinical Practice Initiative
Risk Stratification for Care Management

2. Aims Risk Stratification and Care Coordination Answer the “why”
Identify components of a robust risk tool
Understand the connection between risk
stratification and care coordination.
Identify potential significant risk factors

3. All information was obtained from the American Academy of Family Physicians website and documents.

4. Why risk stratify your patients?
Identifies the patient’s needs to plan, develop and implement a personalized care plan by the care team.
Targets those patients that need aggressive treatment / intervention.
Identifies patients that need more robust care coordination with other providers, or collaboration with community resources.
Reduces the high utilization of resources while reducing the unnecessary re-admission rate.
Achieves the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to a higher risk category with higher costs.
Facilitates population profiling – this analysis will assist in understanding the current and future needs of the whole population and commission services appropriately. 1. 2. 3. 4. 5. 6.

5. Risk Stratification Tool Components
Collect necessary demographics
Assess static risk factors
- Language barriers
- Number of chronic conditions
Assess dynamic risk factors
- Lack of PCP or infrequent visits
- Housing barrier Food insecurity
- Mobility barrier
- Social support

6. Identifying Health Risk Category
The provider / care team will identify the patient’s health risk via the following:
Health Risk Appraisal
Clinical Diagnoses
Utilization data from insurer or other source
Clinician’s personal knowledge related to patient’s total social, financial, mental or physical condition

7. Risk Stratified Care Management
Periodic and systematic assessment of each patient’s health risk status
Using criteria from multiple sources to develop a personalized care plan
Health status is reflected by a score or placement in a specific category based on the most recent health assessment
Stratification assists the care team in predicting health needs and identifying appropriate preventive and chronic care services
Facilitates collaboration between care team and patient/ family in developing a plan of care
Care plans and risk stratification levels are expected to fluctuate due to exacerbation of chronic conditions or changes in patient health

8. Identifying Potential Risk Factors

9. LOW RISK MODERATE RISK HIGH RISK
Primary Secondary Tertiary

11. Risk stratification of a diabetic patient

14. Core Heart Medical Center (cardiology specialty)
Use cardiology-related clinical factors to determine risk
Minnesota Living with Heart Failure questionnaire Guyatt responsiveness index (stratification tool) for measuring quality of life for HF patients.
Canadian Cardiovascular Classification tool (Measure Angina)
Utilize screening tools for COPD and falls
Started gathering data on depression January 2017 using the PHQ-9.

15. Identification Process & Follow up
EHR automatically populates alerts for screenings and evidence-based treatment options based on level of risk. For high-risk patients, nursing staff perform care coordination functions.
Preventive health reminders are built into the EHR
EHR algorithms determine when assessments and reassessments are needed, as well as determining the appropriate time frame for additional testing and follow up appointments (1 month, 3 months, or 1x/year
This algorithm creates a stop gap measure so patients that miss appointments can be followed up on in a timely manner.

16. Total Care Management Case Management Care Management
The collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes
Case Management
Package of physician supervised interventions that assist patients & their support systems in managing medical conditions and related psychosocial problems. Seeks to improve patients’ functional health status, eliminating the duplication of services, and reducing the need for expensive medical services
Patient, Family and Care Giver
Care Management