Population Health Management and Risk-stratfied Care Management

Implement RSCM

The AAFP has created a comprehensive rubric to help you identify your patients' risk category. This full-color PDF can be printed legal- or poster-size for guidance through the RCSM process.

Free for Members
Log in to your AAFP member account and download the PDF for free (a $50.00 value)!

Non-members: purchase the downloadable, full-color PDF.
Non-member price: $50.00

High-Impact Change: Population Health Management

Population health management lies at the core of the PCMH model. It requires practices to regard patients as individuals and as members of a population. Doing so allows a practice to identify the pressing and pending health needs of its patient population, and determine how best to prevent or meet those needs. Population health management involves a proactive, team-based approach to care that focuses on prevention, early intervention, and close partnerships with patients to tightly manage chronic conditions.

Population health management enables a practice to more easily:

  • Proactively identify patients who need evidence-based chronic or preventive care using health data collected and stored in patient registries.
  • Provide planned care and outreach based on patient diseases or conditions.
  • Provide patient self-management support.
  • Monitor patient progress, identify appropriate care plans, and recommend changes to care plans by including prompts in the electronic health record.
  • Monitor practice performance by tracking patient data and comparing it with national guidelines or internal benchmarks.

High-Impact Change: Risk-Stratified Care Management

Risk-stratified care management (RSCM) is the process of assigning a health risk status to a patient, and using the patient’s risk status to direct and improve care. The goal of RSCM is to help patients achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to higher-risk categories and higher associated costs.

Identifying a patient's health risk category is the first step toward planning, developing, and implementing a personalized 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.

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 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(www.commonwealthfund.org)).

Efforts to implement RSCM have the added benefit of preparing a practice to respond to payment reform. Future health care payment models will likely require practices to have a method for systematically categorizing and monitoring their patient populations, so that reimbursement adjustments can be rendered for the additional care and resources the health care team provides to high-risk patients.

Implement RSCM

The AAFP has created a comprehensive rubric to help you identify your patients' risk category. This full-color PDF can be printed legal- or poster-size for guidance through the RCSM process.

Free for Members
Log in to your AAFP member account and download the PDF for free (a $50.00 value)!

Non-members: purchase the downloadable, full-color PDF.
Non-member price: $50.00