When supporting the care of an empaneled group of patients, it’s clear there will be differing individual patient needs. A critical next step following empanelment is risk stratification of the patient population. Population Health is at the core of quality improvement efforts and value-based contracting. Data and technology support practices and networks with needed visibility to identify and close gaps in care and to make informed decisions based on the needs of their unique patient population. Decision support and protocols allow the care team to proactively plan for patient interaction and operationalize evidence-based guidelines. Registry functions optimize the health of an entire panel of patients instead of only the patients who visit the practice.

Insight to patients who are at risk or may soon be at risk informs practices and networks as to how to allocate care team resources.  Patients with multiple chronic conditions, frequent ED and hospital admissions, and behavioral health needs, for example, are likely to benefit from the support of a care manager role whether embedded in the practice or centralized as part of an integrated delivery network.

This section will support care teams and network leaders in designing and implementing an effective care management strategy that addresses the needs of high risk and rising risk patients, provides additional support for patients between visits, and employs overall episodic and longitudinal care management workflows to impact key process and outcome measure performance.

Establishing a care management program requires planning, teamwork, and structure. In addition to working with patients, care managers must consider how their services are communicated to the public, which patients they will work with, how those patients will come to them, and how activity and outcomes will be reported. This self-assessment allows you and your team to review the current program structure to validate what your practice has accomplished and identify those areas that need additional attention. 


Engaged individuals empowered with technology have been transforming every industry for some time. Health care has lagged behind this revolution, but it is catching up. Considering the prevalence and impact of heart disease and stroke, technology that empowers this patient population to achieve healthier lifestyles and better medication adherence should be among the highest priorities for health systems in the US and Canada.


This infographic illustrates the process flow for planned care in the primary care setting. 


The Care Plan tool is designed to help document a patient-directed, whole-person-centered care plan. Using it requires bidirectional communication among the patient, family caregiver(s), and the health care team. Care Plans are especially appropriate for use with high-risk and/or vulnerable patients.


Practice Credits 63% Drop in ACSC Admissions to ‘Going All In’
UC Health – Timberline Medical, Estes Park, Colorado; system-affiliated; 3.5 providers; 3,900 patients

Once you have selected a risk stratification methodology, you must then apply that methodology to your assigned panel. Implementing risk stratification will require an investment of time for those on the project team due to the initial evaluation and validation of the methodology. In addition, you will need to develop an ongoing process to complete the initial assignment of risk in addition to re-evaluating your patients periodically.

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