Milestone 10 Summary

Description: Practice provides care management for patients at highest risk of hospitalizations and/or complications and has a standard approach to documentation. 


What does success look like?


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Practice has not identified an approach for identifying and providing care management for patients at highest risk of hospitalizations and/or complications. Practice identifies high risk patients but is not consistently able to provide care management to those at highest risk. Practice has assigned accountability for care management and is piloting a process for standardizing care management for patients determined to be at highest risk of hospitalizations and/or complications. The care team consistently provides care management for patients at highest risk of hospitalizations and/or complications and has a standardized approach to documenting the care management plans.

Note: numbers are PAT scores


Why is this important?

The ability to identify patients’ health risk level is particularly important under the Affordable Care Act.1 A study conducted by the Commonwealth Fund found that 20% of the patient population accounts for nearly 80% of total medical costs.1 Furthermore, over half of the population incurs very few healthcare costs, accounting for only 3% of medical spending.1 Alternative payment models are likely to usher in risk-adjusted payment models, already in place in many states, requiring practices to have a systematic strategy for risk-stratification of their patient population.2

The ability to assign a health risk score or level to patients allows the care team to create personalized care plans designed to prevent progression into higher-risk categories associated with higher costs.2 Care coordination for patients with multiple chronic conditions can reduce unnecessary healthcare utilization and improve health outcomes.3 Risk stratification allows practices to focus care coordination efforts towards patients most likely to benefit from these services3 while systematically directing patients to appropriate clinicians ensures staff are able to operate at the top of their license.4


Potential Tactics

  • Development of a care management template that allows for individual flexibility
  • Clear assignment of responsibility for overseeing implementation and management of risk-stratified care management processes
  • Clear process for reviewing risk-stratified care coordination plans
  • Updated list of community based resources


Tools and Resources


What might this look like in practice?

After implementation of a standardized risk stratification approach, assigning each patient to one of three categories: Level 1 – primary prevention; Level 2- secondary prevention; or Level 3- tertiary prevention/terminal care,5 all Level 3 patient charts were reviewed in detail. Shared Care Plans were reviewed with the patient at the next clinic appointment with a set of 5 standard areas addressed (medication management, disease status goals, social needs, mental health status, quality of life). For patients without a care plan, one was created with the patient at the next appointment. Care plan review included updating of specialty care providers outside of the practice and linkage to community-based resources to address social and behavioral needs. A copy of the care plan was provided to the patient at the end of the clinic visit and another filed in the medical record.



  1. Mark A Hall. Risk Adjustment Under the Affordable Care Act: A Guide for Federal and State Regulators. The Commonwealth Fund. May 2011. Commonwealth Fund pub. 1501 Vol 7.
  2. High Impact Changes for Practice Transformation. High Impact Change: Risk-Stratified Care Mangement. American Academy of Family Physicians. Accessed October 18, 2016. Available at:
  3. Hass LR, Takahashi PY, Shah ND, Stroebel RJ, Bernard ME, Finnie DM, Naessens JM. Risk-Stratification Methods for Identifying Patients for Care Coordination. Am J Manag Care. 2013 Sep;19(9):725-32. PMID: 24304255
  4. Amanda Berra. Risk-Stratifying Patients- Two Example Approaches. The Advisory Board. April 4, 2011. Available at:
  5. Jill M. Gregoire. An Example of Risk Stratification for Case Management in Primary Care. Indian Stream Health Center. Colebrook, NH. October 22, 2014. Available at: