• Value-based Payment

    AAFP Tools Ease Patient Risk Stratification, Care Planning

    May 5, 2021, 4:33 p.m. News Staff — In 2001, the Institute of Medicine (now the National Academy of Medicine) declared that fundamental health care reform was necessary “to ensure that all Americans receive care that is safe, effective, patient-centered, timely, efficient and equitable.” Spurred by that and similar calls for high-quality care, value-based payment evolved as a methodology for balancing health care effectiveness with efficiency. 

    The AAFP has for many years recognized the potential of VBP as a way of assuring that patients receive the right care at the right time in the right setting and, in 2009, set forth a lengthy roster of principles and guidelines that should be considered when designing and deploying VBP programs.

    According to policy adopted by the 2016 Congress of Delegates, VBP’s focus on health outcomes dictates that practices maintain an infrastructure that supports population health management using risk-stratification care strategies, which starts with attributing patients to a primary care physician. “By identifying panels, physicians and their care teams are able to risk-stratify patients based on the individual care and support needs of each individual patient, thereby allowing for a current state assessment of the health of the population and a gap analysis of resource needs,” the policy states.

    At the practice level, risk stratification is typically performed using an algorithm in the EHR, registry or population health system. Such tools are designed to identify patients who require outreach, have care gaps, or who are due for preventive screenings. Once identified, the care team can reach out to them with reminders and follow up via telephone, the patient portal, mailings or other means.

    For practices that do not have access to these types of systems, the AAFP’s Risk-Stratified Care Management Scoring Algorithm can be useful in stratifying patients into three risk levels based on utilization, chronic disease status, behavioral and mental health, and social determinants of health. The tool enables practices to generate a score and associated risk level to identify patients who may benefit from longitudinal care management services.  

    After a patient’s score and initial risk level have been determined, the care team may wish to use the Risk-Stratified Care Management Rubric to further explore the patient’s risk status and identify care plan suggestions and opportunities for planned care, if appropriate.

    Created by AAFP subject matter experts, the rubric offers a conceptual framework to guide the physician and care team through the process of stratifying patients into six risk-based levels based on health severity, social determinants and utilization of care services. In addition to aiding clinicians in identifying and assigning a patient's health risk level, the rubric can be used to offer care plan suggestions. It includes a diabetes example case that illustrates different risk levels and associated care plan suggestions.

    Both of these risk-stratification resources are available free to members ― that’s a $50 value for each tool.