1. Assigning Risk Categories to Patients
Presented By
Angie Garner
PCMH CCE, CHTS-PW

2. Development
Needed a better way to serve our patients and identify the vulnerable population as we transformed into a Patient-Centered Medical Home Model.
NCQA Risk Levels integrated into the Electronic Health Record
Risk-Stratified Care Management and Coordination document developed by the American Academy of Family Physicians

3. PURPOSE
The purpose of assigning a risk category to a patient is that it is the first step in developing and implementing a personalized patient care plan.

4. The number the patient is assigned will determine which patients are followed by the Care Team Nurses.
Care Team Nurses will be assigned to follow patients who have the assignment of 4,5 and 6.

5. What does it look like?
Scheduling

6. Provider Schedule

8. How do we do it?
If the patient is new to the clinic, the first provider to see the patient will assign a risk category.
If the patient has been seen in the clinic previously, the provider who is the first to see the patient after this procedure (assigning a risk category) is in place will be the one to assign the risk category.

9. A patient’s risk category shall be evaluated at every visit for potential changes.
Providers can change a patient’s risk category depending on the provider’s findings after an encounter with the patient.

10. Changes to the risk category can only be made by providers
Changes to the risk category can only be made by providers. However, Care Team Nurses may suggest to a provider a change in patient’s risk category.
Each medical provider will be provided with the document called “Risk-Stratified Care Management and Coordination” originally developed by the American Academy of Family Physicians to assist in assigning a patient’s risk level.

15. Primary Prevention Level One:
Patients who are healthy and have no known chronic diseases

16. Primary Prevention Level Two
Patients who are healthy but showing warning signs of potential health risks.

17. Secondary Prevention
Level Three
Patients who have a chronic disease, are managing well, and meeting their desired goals. Patients with a mental health diagnosis are included as having chronic diseases. Patients deemed level three should have a yearly visit with the BHC.

18. Secondary Prevention
Level Four
Patients who are not in control of their chronic disease, but as of yet, have not developed complications. Patients with serious mental illness such as schizophrenia, bipolar, or schizoaffective disorder are included in this category. These patients should have on-going visits with the BHC and should be referred to the Care Team Nurse by the providers

19. Tertiary Prevention
Level Five
If a patient’s chronic disease has progressed, become unstable, or new conditions and/or significant complications have developed. Also, patients that have a risk of being hospitalized, or who have been recently hospitalized are in this group. These patients should have on-going visits with the BHC, and be referred to the Care Team Nurse by the providers.

20. Catastrophic
Level Six
Level six is for patients in extreme situations such as a baby who needs long-term care or a patient with a severe head injury. These patients may be under the care of specialists and are often receiving institutional care. These patients and their families may be referred to the Care Team Nurse as appropriate

21. Benefits of assigning a Risk Category
To the patient – a nurse or care manager who will help them manage their chronic disease. The patient will feel that the office cares for them and their issues, thus increasing patient satisfaction.
To the provider – a nurse or care manager who will glean more information for them and do the education that is needed as well as follow-ups on your orders. This will hopefully end in better health outcomes.

22. Benefits of assigning a Risk Category
Identifies patient who need care management to ensure
they are receiving a person–centered care plan. (PCMH)
Screen patients for Social Determents of Health (PRAPARE tool)
Scheduling using acuity risk to help with workflow and give time for nurses, providers and BHC’s to see the patients who have been identified.

23. Benefits of assigning a Risk Category
Helps determine staffing needs
2018 YTD
Level %
Level %
Level % 1,960
Level % 1,691
Level %
Level %
2,194 at risk patients to date.

24. Questions?