Milestone 9 Summary

Description: Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk.


What does success look like?


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Practice does not have a defined process for identifying patient risk level. Practice has a process for identifying high risk patients but the identification process for other risk levels is inconsistent or not yet standardized. Practice has introduced a standard process for identifying patient risk level and is developing corresponding descriptions of the type of care required at each level. Practice has successfully implemented and documented a tested process that identifies patient risk level and includes follow up by the patient’s care team with care appropriate to the risk level identified.

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 stratified managed care (also known as empanelment) allows practices to focus care coordination efforts towards patients most likely to benefit from these services.3


Potential Tactics

  • Determine a risk-stratification model most appropriate and feasible for your practice
  • Implement a risk-stratification model consistently into the medical record
  • Validate the risk-stratification approach among 20 known high-utilizers/high-care needs patients using clinician and patient/family feedback
  • Integrate patient risk into patient care discussions and care team assignments
  • Identify a practice manager for risk stratification and panel management
  • Integrate risk assessments into Shared Care Plans


Tools and Resources


What might this look like in practice?

A mid-sized clinic in Indiana set out to implement risk-stratified care management into their primary care clinic. Over the course of a few months, physicians and their care teams reviewed clinical data and utilization data to complete a health risk appraisal form for each patient. Provider knowledge was also used to complete this risk assessment, taking into consideration known social characteristics of the patient. Each patient was then assigned to one of three categories: Level 1 – primary prevention; Level 2- secondary prevention; or Level 3- tertiary prevention/terminal care. These categories allowed for stratification by both disease burden (none, well managed, unstable) and healthcare utilization (low, moderate, high). Risk assignments were used to adjust patient panels according to the most qualified provider. On an annual basis (or as needed), each patient’s risk level is reassessed by the care team by revisiting the risk assessment with the patient and/or patient family. This review is used to guide the development and ongoing management of Shared Care Plans.



  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. 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: