Risk-stratified Care Management

Risk-stratified Care Management

What is risk-stratified care management?

Risk-stratified care management begins with a periodic and systematic assessment of each patient's health risk status, using criteria from multiple sources to develop a personalized care plan. A patient's health status may be reflected by a score or placement in a specific category, based on the most current information available.

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 identification of a patient's health risk category is the first step towards planning, developing and implementing a personalized patient care plan by the care team, in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other providers, intensive care management, or collaboration with community resources.

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)

Although many insurers already use sophisticated analytical tools that assign risk scores to patients, they may be missing the clinician's important and personal knowledge about the patient. The health care team's additional observations play a vital role, and the more variables that are included in determining the risk category, the more reliable and accurate the prediction of future health risks and costs. For some patients, it may even be possible to return to a lower risk category once care plans and interventions have been implemented.

Health Risk Categories

There are many options to score or categorize health risk once the patient's information has been collected. One simple method creates six levels of risk within the three existing public health prevention categories to determine the patient’s health status. The next step is the creation of a collaborative, personalized, and pro-active care plan to address the patient's needs.

  • 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 are further defined in Table 2(1 page PDF), which uses an example of a patient who has uncontrolled progressive diabetes. Suggestions are provided for various care plan components for this example case.

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.

Risk-stratified Care Management- Health Risk Categories