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VALUE TRANSFORMATION FRAMEWORKAction GuideCARE DELIVERYHEALTH CENTERINFRASTRUCTUREPEOPLEPOPULATION HEALTH MANAGEMENTRISK STRATIFICATIONWHYRisk Stratification?Risk stratification enables providers to identify the right level of care andservices for distinct subgroups of patients. It is the process of assigninga risk status to patients, then using this information to direct care andimprove overall health outcomes.Population health management requires practices to considerpatients as both individuals and as members of a larger community orpopulation. At the individual level, a patient's risk category is the firststep towards planning, developing, and implementing a personalizedcare plan. One common method of segmenting patients is by “risk”level: high-, medium- (rising), and low- risk. At the population level, riskstratification allows care models to be personalized to the needs ofpatients within each subgroup. (See Models of Care Action Guide.)POPULATIONHEALTHMANAGEMENTThe Value TransformationFramework addresses how healthcenters can use a systematicprocess for utilizing data on patientpopulations to target interventionsfor better outcomes, with a bettercare experience, at a lower cost.This Action Guide focuses onone foundational component ofpopulation health management: riskstratification.A "one-size-fits-all" model, where the same level of resources is offeredto every patient, is clinically ineffective and prohibitively expensive.To maximize efficiency and improve outcomes, health centers mustanalyze their patient population and customize care and interventions based on identified risks andcosts1,2,3,4,5. Healthy patients, for instance, may not want a high level of intensive support, and can beengaged through alternate models of care2. With this in mind, high-intensity resources canand should be reserved for high-risk patients. Care models based on risk with customizedcare at each level can flexibly match need with more appropriate resources1,2,3,4,5.Top-performing, population health-focused organizations practice riskstratification.WHATis Risk-Stratification?The goal of risk stratification is to segment patients into distinct groups of similar complexityand care needs. For example, out of every 1,000 patients in a panel, there will likely be close to 200 patients(20%) who could benefit from more intensive support. This 20% of the population accounts for 80% of thetotal health care spending in the United States5,6. Of these “higher need” patients, five percent (5%) accountfor nearly half of U.S. health expenditures6,7. Health care spending for people with five or more chronicconditions is 17 times higher than for people with no chronic conditions8. 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019

HEALTH CENTERCARE DELIVERYINFRASTRUCTUREPEOPLEPOPULATION HEALTH MANAGEMENTRISK STRATIFICATIONSegmenting the population according to health care needs allows health centers to do a better job oftargeting resources more efficiently and at a lower cost. Risk groupings can include: highly complex, highrisk, rising-risk, and low-risk individuals. Unique care models and intervention strategies are then used foreach group. ighly complex. This is a small group of patients with the greatest care needs.HThis group, likely less than 5% of the population, has multiple complex illnesses,often including psychosocial concerns or barriers. Care models for this populationrequire intensive, pro-active care management. The goal for this group is to uselower-cost care management services to achieve better health outcomes whilepreventing high-cost emergency or unnecessary acute care services. igh-risk. The next tier includes patients with multiple risk factors that, if leftHunmanaged, would result in them transitioning into the highly complex group. Ittypically describes about 20% of the patient population. This cohort of patients isappropriately engaged in a structured care management program that providesone-on-one support in managing medical, social, and care coordination needs. Acare manager works with patients to ensure that they receive appropriate chronicdisease management and preventive services.Rising-risk. This tier includes patients who often have one or several chronicconditions or risk factors, and who move in and out of stability with theirconditions. One analysis showed that extending care management to thispopulation reduced the number of patients who moved to the high-risk group by12%, with a 10% decrease in overall costs2. With rising-risk patients, successfulmodels of care focus on managing risk factors more than disease states2. Commonrisk factors include: obesity, smoking, blood pressure, and cholesterol levels.Identifying these risks enables staff to target the root causes of multiple conditions.Low-risk. This group includes patients who are stable or healthy. These patientshave minor conditions that can be easily managed. The care model for this groupaims to keep them healthy and engaged in the health care system, without the useof unnecessary services.2Value Transformation Framework Action Guide 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019

HEALTH CENTERCARE DELIVERYINFRASTRUCTUREPEOPLEPOPULATION HEALTH MANAGEMENTRISK STRATIFICATIONHOWto Risk Stratify?There are many approaches to risk stratification. Some are very complex andcostly, but simpler approaches (like those outlined in this Action Guide) are alsoeffective, particularly for organizations just getting started. One study that lookedat six common risk stratification approaches found that the Adjusted ClinicalGroups (ACGs) model developed by Johns Hopkins was best able to identify the top10% of high cost users1. Yet, the study concluded that ‘any of these models will helppractices implement care coordination more efficiently’. This Action Guide recommends starting with acore component found within many of the complex models—condition counts—as a simple and easymethod for health centers to segment patients into risk categories (risk stratification).The process of stratifying by condition counts (the number of conditions per patient) helps to identify acohort of high-risk individuals who can benefit from one-on-one care management. This process can besupplemented by provider and care team referrals. Health center staff can consider the severity of disease,social risks, and utilization patterns in identifying patients who fall outside of the high-risk group but whomay benefit most from care management.RISK STRATIFICATION STEPS:Outlined below is a straightforward process to categorize patients’ risk level by number of clinicalconditions. Grouping patients by risk level allows a health center to direct care and resources to theneeds of each subgroup.STEP 1 Compile a List of Health Center Patients: Create a complete list: include not only patientswho come in for care, but also individuals who have been assigned to your health center.STEP 2 Sort Patients by Condition: Use the Uniform Data System (UDS) Table 6A measures or a listthat’s appropriate to your patient population.STEP 3 Stratify Patients to Segment the Population into Target Groups: Start by using thesimple but effective method of “condition counts” (the number of conditions per patient).STEP 4 Design Care Models and Target Interventions for Each Risk Group: Each cohort (highlycomplex, high-risk, rising-risk, and low-risk) should be matched to a care model that meetstheir needs. (See Models of Care Action Guide.)Compile a list of health center patients. Generate a list of all patients attributed to yourorganization or target site. This should include those who come in for care and those whohave been assigned to your health center by payers or other groups. If you are interested in aparticular age group, narrow your list to that target audience (e.g., adults 18 years of age).Action item: Compile a list of all attributed patients.3Value Transformation Framework Action Guide 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019

HEALTH CENTERCARE DELIVERYINFRASTRUCTUREPEOPLEPOPULATION HEALTH MANAGEMENTRISK STRATIFICATIONSort patients by number of conditions. Using your patient list, match patients againstclinical conditions using the Uniform Data System (UDS). This Action Guide uses a subset ofthe UDS Table 6A measures (see footnotes below). This list represents the conditions withthe highest prevalence among health center patients. Based on local health conditions andclinical priorities, health centers may choose to match patients against a different list. Action Step: Match the list of patients against selected diagnoses (such as thebelow list from UDS Table 6A).UDS High-Risk ConditionsApplicable ICD-10-CM Code*Cancer (abnormal cervical findings)C53-, C79.82, D06-, R87.61, R87.629,R87.810, R87.820Heart DiseaseI01-, 102- (exclude 102.9), 120- through125-, 127-, 128-, 130- through 152-Chronic Lower Respiratory DiseasesJ40- through J44-, J47-AsthmaJ45-DiabetesE08- through E13- O24- (exclude O24.41-)HTNI10- through I16-ObesityE66-, Z68- (exclude Z68.1, Z68.20 throughZ68.24, Z68.51, Z68.52)DepressionF30- through F39-Other mental disordersF01- through F09- (exclude F06.4), F20through F29-, F43 through F48- (excludeF43.0 and F43.1), F50- through F99- (exclude F55-, F84.2, F90-, F91-, F93.0, F98-),099.34 R45.1, R45.2, R45.5, R45.6, R45.7,R45.81, R45.82, R48.0The above list of conditions match HRSA’s Reporting Instructions for 2018 Health Center Data for Table 6A, including the diagnosticcategories and applicable ICD-10-CM codes on pages 72-75. Using the above as a starting point, health centers can add/subtractconditions (e.g., “other substance related disorder (excluding tobacco use disorders) or other diagnostic categories” or “alcohol-relateddisorders“ based upon local health conditions and clinical priorities or other conditions).*Wherever possible, diagnoses have been grouped into code ranges. Where a range of ICD-10-CM codes is shown, health centers shouldreport on all visits where the provider-assigned diagnostic code is included in the range/group. All diagnoses reported for the visit (e.g.primary, secondary, tertiary) are reported on Table 6A if they are included in the range of codes listed. Each diagnosis made at a visit iscounted regardless of the number of diagnoses listed for the visit.’4Value Transformation Framework Action Guide 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019

HEALTH CENTERCARE DELIVERYINFRASTRUCTUREPEOPLEPOPULATION HEALTH MANAGEMENTRISK STRATIFICATIONStratify by condition count. Using information from Steps 1 and 2, group patients by thenumber of conditions they have. Individual health centers may have slightly different “cut-offs”for the four risk groups. In general, the highly complex group will include patients with 6 ormore chronic conditions. High-risk will include patients with condition counts in the range of4-5. Rising-risk will include those with 2-3 conditions. Patients with 0-1 selected conditions willcomprise the low-risk group. Action step: Segment the population into target groups based on the number ofconditions per patient.Risk Level# ConditionsHighly complex7 Highly k2Low-risk0 or 1TotalCumulative TotalProviders and members of the care team can adjust stratification based on personal knowledgeof each patient's utilization patterns, social risks, and other factors.Design care models and target interventions for each risk group. After segmenting thepopulation into target groups, health centers can then match internal capabilities and externalresources to meet the unique needs of each patient. Action Step: Design care models for each cohort (highly complex, high-risk, rising-risk, andlow-risk) that target interventions to the specific needs of each subgroup. (See Models ofCare Action Guide.)References 1. Haas, L.R., Takahashi, P.Y., Shah, N.D., Stroebel, R.J., Bernard, M.E., Finnie, D.M., Naessens, J.M. (2013). Risk-Stratification Methods for Identifying Patients for CareCoordination. American Journal of Managed Care. 19(9), 725-32.2. The Advisory Board Company. (2013). Playbook for Population Health, Building the High Performance Care Management Network. Washington, DC: The Advisory BoardCompany.3. Mathematica Policy Research. (2015). Evaluation of the Comprehensive Primary Care Initiative: First Annual Report. Princeton, NJ: Mathematica Policy Research.4. Porter, S. (2014). Identifying High-risk, High-cost Patients Is Step One to Improving Practice Efficiency. AAFP News. November 4, 2014. Retrieved from: ues/20141104riskstratify.html.5. American Academy of Family Physicians, Practice Management, High Impact Changes for Practice Transformation. (August 20, 2017). Retrieved from: tion/pcmh/high-impact.html#rscm.6. Hall, M. (2011). Risk Adjustment Under the Affordable Care Act: A Guide for Federal and State Regulators. Issue Brief #1501(7). New York, NY: The Commonwealth Fund.7. Conwell, L.J., Cohen, J.W. (2005). Characteristics of People with High Medical Expenses in the U.S. Civilian Noninstitutionalized Population, 2002. [Statistical Brief #73]. Rockville,MD: AHRQ.8.Anderson, G. (2010). Chronic Conditions: Making the Case for Ongoing Care. Princeton, NJ: Robert Wood Johnson Foundation.9. Health Resources & Services Administration, Bureau of Primary Health Care. (2016). Uniform Data System Reporting Instructions for 2016 Health Center Data. Rockville, MD:HRSA, BPHC.5Value Transformation Framework Action Guide 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019

Value Transformation rameork Action Guide 2019 National Association of Community Health Centers. All rights reserved. [email protected] July 2019