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


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.


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 physicians know when patients have been to the ED.

3. Post-hospital care. Following up is also important after a hospital admission. Preventing readmissions is key to the cost-saving goals of value-based care, and transitional care management also provides enhanced reimbursements.

4. Closing quality and risk gaps. Accurate risk coding and access to data on patients' health burdens can enable practices to better understand their attributed population, identify care gaps, and deploy resources wisely.


Success in value-based payment models often requires family medicine practices to have robust referral networks for services patients need outside traditional primary care. This includes behavioral health services such as substance use disorder (SUD) treatment and recovery management, which have become even more important as overdose deaths have increased dramatically during the COVID-19 pandemic.1

Meanwhile, value-based care is expanding to include SUD treatment programs. Many of these programs now must ensure clients receive health maintenance screenings and medical treatments that are outside their traditional scope of services. At the same time, many SUD treatment programs are also dealing with staffing shortages and budget shortfalls.2

It's more crucial than ever that primary care practices and community-based SUD treatment providers work together. Collaboration creates win-win opportunities in value-based payment programs and better clinical outcomes. In addition to making referrals, co-locating is an option. The expansion of telehealth during the pandemic has removed logistical barriers to co-locating SUD treatment within family medicine practices.

If your practice has struggled to connect patients to SUD treatment providers, now is an ideal time to forge partnerships. To find state-licensed SUD treatment providers in your area, go to and enter your ZIP code into the search field.


Practice Pearls presents readers' advice on practice operations and patient care, along with tips drawn from the literature. Submit a pearl (250 words or less) to FPM at

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