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.