A Practical Risk Stratification Approach for Implementing a Primary Care Chronic Disease Management Program in an...

Area of Science:

• Health Services Research
• Primary Care Medicine
• Population Health Management

Background:

• Value-based care often relies on payer incentives.
• Effective population health management requires practices to define and manage their own patient panels.
• Identifying patients with high comorbidity is crucial for panel management.

Purpose of the Study:

• To develop and test a simplified risk stratification method for identifying high-comorbidity patients within a primary care setting.
• To enable effective population health management independent of payer-specific metrics.

Main Methods:

• Utilized internal electronic health record and billing data from an urban academic family medicine clinic.
• Employed a simplified risk stratification model based on ICD-9 codes.
• Analyzed a patient panel of 5,364 individuals over a two-year period.

Main Results:

• Identified 347 high-risk patients (6.5%) within the 5,364 patient panel.
• The average age of high-risk patients was 59 years (SD 15).
• Common conditions in high-risk patients included hypertension (90%), hyperlipidemia (62%), and depression (55%).

Conclusions:

• Simplified risk stratification is a feasible strategy for practices to understand and manage population health.
• This approach supports proactive care for underserved communities with complex health needs.
• Empowers primary care practices to engage in population health management.