Risk Stratifying Populations

Risk Stratifying Populations
Part of patient-centered care is using your practice’s resources in a way that can have the greatest positive impact. It’s difficult to know where to focus your time and attention without some population health analysis.  
Stratifying populations is a way to identify the patients who can most benefit from additional guidance and attention from the practice care team, then identify the interventions that will do the most good.  
A risk stratification score can be a simple list of any combination of the following variables, including but not limited to: patient demographics; utilization; diagnoses; prescription fill information; co-morbidities and historic costs.  
We provide participating practices tools and resources to get started with risk stratification and population health management. This section of the Provider Toolkit includes inputs from an academic and best practice perspective, as well as a systems approach. The information in this toolkit is meant to help participating practices build a foundation for risk stratification methodologies, then expand and refine methodologies as practice capabilities grow.  
A guide to care management for patients with chronic conditions, limited functional status, or psychosocial needs. This toolkit can help improve an existing care management program or launch a new one.  
This brief guide from the American Academy of Family Physicians (AAFP) outlines how risk stratification works, and how it can help providers focus attention on the population of patients who can most benefit from care management.  
Nine things physicians and teams need to understand about risk stratification as suggested by co-authors Patrick Gordon (executive director of the Colorado Beacon Consortium) and Asaf Bitton, MD (primary care physician and senior advisor to CMS' Comprehensive Primary Care initiative).  
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