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Risk-Stratified Care Management
What is risk-stratified care management?
This assessment will assist the physician and care team in predicting health care needs and recommending appropriate preventive and chronic care services. Based on the outcome of the risk assessment, a personalized care plan can then be developed in collaboration with the patient and /or family. The care plan or category of health risk may fluctuate due to expenditures or significant changes in the patient's health.
Why is risk-stratified care management important?
The goals are to help the patient achieve 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.
In a practice panel of 1,000 patients, there will likely be close to 200 patients (20%) who could benefit from an increased level of support. This top 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1% (via the Commonwealth Fund Issue Brief, May 2011).
Lower risk patients may warrant incrementally increased support and management as they move from a healthier category to one of higher risk.
Future payment models will likely require a practice to have a method to systematically identify and monitor their patient population, so that reimbursement adjustments can be rendered for the additional care and resources provided to high risk patients by the health care team.
Significant Risk Factors to Consider When Assigning a Patient’s Category or Score
- Patient's health risks as identified by a health risk appraisal form or other questionnaire
- Clinical diagnoses
- Utilization data from insurer or other source
- Clinician’s personal knowledge related to a patient’s social, financial, mental, or physical condition: see Table 1 (1-page PDF file; About PDFs)
Health Risk Categories
- Primary Prevention (Level 1 and 2): Patients who are healthy and have no known chronic diseases could be assigned to a low risk category, or Level 1. Patients who are healthy but showing warning signs of potential health risks may be assigned to Level 2. Patients in the primary prevention category tend to be lower in their health care resource expenditures.
- Secondary Prevention (Level 3 and 4): A patient who has a chronic disease, is managing it well, and meeting their desired goals, may be assigned to an intermediate category (Level 3). Those who are not in control of his/her disease but have not developed complications may be assigned to Level 4. Patients in the Secondary Prevention category tend to be moderate users of health care resources.
- Tertiary Prevention (Level 5): If a patient's chronic disease has progressed, become unstable, or new conditions and/or significant complications have developed, they may progress to the tertiary category (Level 5). Patients in the tertiary prevention category usually rank high in health care resource expenditures.
- Catastrophic (Level 6): An additional, non-public health Level 6 category is reserved for extreme situations, such as a pre-term baby who needs intensive long-term care, a patient who has a severe head injury, or anyone requiring highly complex treatment. Patients in the catastrophic category have extremely high health care resource expenditures and may be under the care of several sub-specialists.
The categories included within the outlined red boxes (Levels 4-6) represent the patients most likely to require or benefit from increased support from the practice team and/or personalized intensive care plans.