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Goal: Practice has successfully implemented and documented a tested process that identifies patient risk level and includes follow up with care appropriate to the risk level identified, including ensuring that those at highest risk receive care management services or have a care plan in place that the practice is following.
Strategies
Strategies
- Identify a risk stratification approach and use it consistently
- Assign responsibility for care management
- Implement a standard approach to documenting care plans
- Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts
- Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients
- Use panel management and registry capabilities to support management of patients at low and intermediate risk
- Engage patients at highest risk in ongoing development and refinement of their care management plan, to include integration of patient goals, values and priorities
- Use the Medicare Annual Wellness Visit with Personalized Prevention Plan Services for Medicare patients
- Use social determinants of health in risk-stratification models
- Assess patient engagement and willingness to address care gaps
- Allow for the common sense addition to high risk or rising risk factor care team – no algorithm is perfect
- Identify ways to graduate patients from care management when goals are met as appropriate
- Deliver care plan with patient and family
- Five minute daily huddles to plan care for the day
- Use risk level to identify best provider for the patient
Resources
Resources
1.3.3 Risk Stratification Tool.pdfGoogle Sites
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