1. Risk Assessment and Stratification
Identifying Highest Risk Patients and Developing Interventions for Them

2. Identify Your Sickest Patients
Right now make a list of the 5-10 patients that worry you the most.
name
Are your lists the same as your co-workers?
Why are these patients on your list?
What can you (provider and care team) do to improve things for each of these patients?
name

3. Systematically Do That
What would happen if you made these lists every week or every two weeks?
Who in your office would be responsible for following up with these patients?
How would you carve out time for these staff to do this follow-up?
How would you document the follow-up care?

4. How Might This Work Daily?
What criteria would you use to classify a patient as high-risk during an office visit?
How might you address the needs of patients you identify as high-risk during office visits?
How can you find out which patients are in the hospital and are being discharged each day?
How can you find out which patients have been in the ER in the past day or two?

5. Why Risk Stratify? Identify patients with highest needs – prioritize.
Utilize limited practice resources effectively.
Use to determine visit frequency.
Maintain access to care.
Biggest bang for the buck is to focus on high risk!
Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events.
Decrease the utilization of resources downstream.
Decrease the overall cost of care.
Shift resources to PCP.

6. Risk Factors to Consider
Degree of Disease Severity
Pick a number for BP, A1C, LDL, etc.
Utilization Frequency
Office Visits
Phone calls to the office
ER visits
Hospitalization
Self-care Deficit
Taking of meds
Following diet
Activity
Social Issues
Phone
Transportation issues
Lack of support at home
Lack of resources $$$$$

7. Looking at Your Highest Risk
A1C >9?
LDL >130?
BP >160/95?
Calculate how many you have?
Maybe you need to start even higher
Looking for the worst 5-10%

8. Looking at Your Highest Risk
Have they been seen in last 6 months?
Bring them in!
What can be done different?
Self-Management Support!
Depression?

9. Step-wise Approach to Risk and Intervention Stratification
Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention
STEP 3
Getting Medium and High Patients in for Follow-up Visits
Step-wise Approach to Risk and Intervention Stratification
STEP 2
Giving DM Planned Care at Every Visit
STE P 1
Building Registry Functionality for Patients with DM

10. Questions?
The second change concept is about how we work together.