Risk-stratified care management rubric and algorithm

You can support your practice's population health management efforts with a coordinating risk-stratification rubric and algorithm tools. Following the steps in these tools will set your practice on the path to high-quality care and can ease you into value-based models.

Risk stratification is a systematic way to group patients by risk level. Having a risk-stratified patient panel makes it easier for family physicians to determine which patients are at high risk for hospitalization or a health crisis that could be prevented with strategic outreach measures.

Use a streamlined algorithm to stratify patients into three risk levels based on utilization, chronic disease, behavioral and mental health, and social determinants of health.

This tool generates a score and associated risk level to identify patients who may benefit from longitudinal care management services.

While many practices have access to a registry or population health system, this algorithm can be helpful for implementing risk-stratified care management in practices that do not.

Once a patient’s score and risk level are determined, the care team can use the risk-stratified care management rubric to identify care plan suggestions and opportunities for planned care, if appropriate.

Guide yourself and your care team through the process of stratifying patients into six risk levels based on factors like health severity, social determinants of health and utilization of services.

The rubric includes the following:

• Framework for identifying and assigning a patient's health risk level
• Care plan suggestions
• Diabetes example case that illustrates different risk levels and associated care plan suggestions

Risk stratification can be used for a number of purposes, including achieving optimal payment for primary care under a value-based care model. Intervening to prevent costly future care can lead to savings for public and private payers, in addition to better health and fewer expenses for patients. In some arrangements (for example, Medicare’s chronic care management), practices are reimbursed for or appropriately paid to sustain quality-oriented efforts and programs.

Getting started with value-based care? A free, member-exclusive CME series offers education and tools that will help you use strategies like risk stratification and make changes that count most for your patients.