PRACTICE PEARLS

 

Fam Pract Manag. 2021 Nov-Dec;28(6):33.

SORT PATIENTS BY RISK: THREE METHODS

Identifying patients at risk of clinical deterioration is key to managing your patient panel effectively in value-based care. Successful primary care practices use risk stratification to identify patients at high risk of hospitalizations or other costly medical events.

There are several risk-stratification methods practices can use. First, physicians can identify which patients carry the highest risk based on their personal knowledge of their patients. Second, practices can leverage technological tools like the Johns Hopkins ACG System (this is just an example, not an endorsement) that combine medical and pharmacy claims with EHR data to identify high-risk patients. Last, practices can partner with a clinically integrated network (CIN) or accountable care organization (ACO). CINs and ACOs can often provide risk-stratification tools to improve shared performance in value-based payment arrangements.

Don't forget that success in value-based care requires acting on these insights. See your highest-risk patients early in the calendar year and with appropriate frequency throughout the year.

FOCUS ON THESE FOUR AREAS FOR VALUE-BASED CARE SUCCESS

Focusing on four key activities can help primary care physicians succeed in value-based care.

1. Access to preventive care. Annual wellness visits are key to keeping patients current on preventive care such as vaccinations and screenings. Medicare annual wellness visits also typically offer more reimbursement than similar evaluation and management visits.

2. Emergency department (ED) follow-up. After an ED visit, ensure patients have access to their medications and are equipped for self-care. Schedule a follow-up visit to talk about potential changes to their care plan. Some EHRs include alerts that let p

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Practice Pearls presents readers' advice on practice operations and patient care, along with tips drawn from the literature. Send us your best pearl (250 words of less), and you'll earn $50 if we publish it. We also welcome questions for our Q&A section. Send pearls, questions, and comments to fpmedit@aafp.org, or add your comments below.

 
 

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