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Risk Stratification and Longitudinal Care ManagementLearning and Action SummaryThis learning and action summary pulls together resources 1, videos 2, and guidance sharedduring various learning events and organizes content, so that you can easily reference materialsas you risk stratify patients in your practice. This guide provides content and resources thatcomplement suggested implementation approaches provided in the CPC ImplementationGuide.Understand the Role of Risk Stratification in CPC ActionResourceUnderstand the goal of risk stratificationin CPC . Review risk stratification in the Key Concepts section ofthe CPC Implementation Guide.Review Function 2: Care Management in the CareDelivery Resource.Watch the CPC Orientation Care DeliveryRequirements video, which depicts the changes in caredelivery requirements from 2018 to 2019, most of whichremain current today. This video can provide practicestaff, especially new hires, a basic orientation to theCPC Care Delivery Requirements.Read this article by the Colorado Beacon Consortium:Predict, Prioritize, Prevent: Nine things practices shouldknow about risk stratification and panel management.Some of the resources listed in this summary report, including tools shared by other practices, reside on CPC Connect. To directly access these links, log in to your CPC Connect account first. If you are not logged in to yourCPC Connect account and select one of these links, you will be directed to the website login page. Log in to thewebsite, then return to this document and select the link again to open a new window.2This icon denotes a live video clip and provides alternative text describing video clip contents. Hover over thisicon with your cursor to view video descriptions.1Page 1 of 7
Select Your Preferred Strategy for Risk StratificationActionResourceUnderstand Two-Step Risk Stratification inCPC . Risk Stratification Algorithm Clinical Intuition Review available risk stratificationmethodologies. Choose, modify, or create a riskstratification methodology that best suitsyour practice. Choose or develop a risk-stratificationmethod. Examine your population using availabledata or clinical team qualitative input. Watch the PIA on What is 2 Step Risk Stratification andHow Does it Work? to understand the CPC two-steprisk stratification process, which includes the use of arisk stratification algorithm and clinical intuition.Resources shared by practices:o Risk Stratification Action Plan (Crystal Lake Clinic)o Risk Stratification Protocol (Crystal Lake Clinic)Review example published risk-stratificationmethodologies:o Hierarchical Condition Category (HCC) (CMS) A prospective model used to calculate riskscores for beneficiaries enrolled in MedicareAdvantage (MA) plans. HCC uses diagnosesbased on face-to-face encounters and modifiedwith Medicaid factors (coefficients) thatcomplement diagnoses.Modify an existing risk-stratification method:o Using the AAFP Model and Clinical Intuition toCreate a Dynamic Two-Step Risk StratificationModelCreate your own risk-stratification method:o Developing a Two-Step Risk Stratification Algorithmo Two-Step Risk Stratification and Creating an AdultRisk Stratification ToolReview tools shared by practices on CPC Connect:o Mercy Family Medicine Adult Risk Stratification Toolo St. Bernard's Clopton Clinic's Four-Stratum RiskStratification Toolo Village Primary Care's Five-Stratum RiskStratification ToolPage 2 of 7
Risk Stratify Your Patient Population and Identify Patients for Care ManagementActionResourceUse risk stratification to identify patientsfor care management. Identify which patients to target Identify care team members to supportpatients with complex needs Use risk stratification to provide targetedlongitudinal and episodic caremanagement. Identify which patients to target Watch the PIA on Using Your Risk Stratification toTarget Care Management to learn how to best use yourrisk stratification process to inform both episodic andlongitudinal care management services.Watch the CPC Pillars of Success: Identifying Patientsfor Care Management video.Resources shared by practices:o Risk Management Process (Randy D. Walker MD)o Risk Management Tool (Randy D. Walker MD)Watch the PIA on Using Risk Stratification to PrioritizeCare Management Services to learn how to best useyour risk stratification process to create and execute aconsistent risk stratification process that targets highrisk populations.Watch the CPC Pillars of Success: Engaging Patientsand Caregivers in Longitudinal Care Managementvideo.Watch the CPC Pillars of Success: Episodic CareManagement video.Read CPC Spotlight 1: Using Risk Stratification toTarget Care Management Resources.Page 3 of 7
Develop Workflows and Strategies to Address the Needs of High-Risk PatientsActionResourceImplement targeted, relationship- basedlongitudinal care management. Build long-term patient relationships. Build your care team and prepare yourstaff for care management. Identify high-risk patients and proactivelymonitor and coordinate care. Meet the needs of high-risk patients. Set goals with the patient and developcollaborative plans. Build a relationship with your patient population:o Steps for Partnering with Patients and Caregiverso Determine the Frequency of Patient Interactions andFollow-upsBuild your care team and include your care manager:o The Roles of the Care Team and Care Managero Important Care Manager Skills and Responsibilitiesfor Longitudinal Care ManagementAddress the needs of high-risk patients:o Use Your Risk Score to Drive Your CareManagement Approacho Target High-Risk Patients for Longitudinal CareManagemento Identify High-Risk Patients and Assess PatientNeeds and Patient ActivationDevelop collaborative care plans:o Use Health IT to Develop Care Plans and EnhanceLongitudinal Care Managemento Use Motivational Interviewing to Identify PatientProgress and Develop Care Plans with the PatientWatch the Personalized Care Planning video.Review tools shared by practices on CPC Connect:o Traverse Bay Internal Medicine's Patient-OrientedAction Plano Advancing Longitudinal Care Management ServicesSnapshoto Expanding Care Management Services in a SmallRural Snapshoto Joint Venture for Care Management ServicesSnapshoto Centralized Quality Team SnapshotPage 4 of 7
Monitor and Refine Your Risk Stratification ProcessActionResourceRefine your risk stratification process. Evaluate results Define the process and frequency Manage effectiveness Monitor and refine methodology Watch the PIA on Risk Stratification: Refining YourProcess Over Time to learn key considerations inmonitoring and adjusting your chosen risk stratificationmethodology over time.Use data to proactively monitor your progress:o Use Your Electronic Health Record (EHR) to TrackProgress on Patients Who Are Risk Stratified andReceiving Longitudinal Care Managemento Use Data to Determine if Your Care ManagementApproach is WorkingDocument risk scores and track progress:o Using EHR Flowsheets and Standardized CarePlans to Manage High-Risk PatientsNetwork with Practices Like YoursActionResourceCollaborate with other practicesimplementing and modifying their riskstratification strategies.o Join discussions in affinity groups withpractices that share your same healthIT vendor to find information on how tooptimize application of your EHR. Join in on the conversation and share best practicesand resources on CPC Connect:o CPC ConnectExplore the frequently asked questions (FAQs), called“Articles,” available on CPC Connect.o Search for FAQs using the CPC Connect universalsearch bar or scan the Articles tabs in the Topicspages.Page 5 of 7
Resource Quick Access ListThis section of the resource and action guide provides a summary list of resources and links.Resource CategoryResource TypeLinkNational WebinarsCPC national webinars are one-hourlearning events that deliver content onspecific CPC change concepts. Links tonational webinars that relate to riskstratification are listed on the right.2017 CareManagementWebinarCare Management WebinarLearning ProductsCPC learning products include on-demandvideos and podcasts. Links to learningproducts that relate to risk stratification arelisted on the right.Learning ProductsCPC Orientation Care DeliveryRequirements VideoCPC Pillars of Success: IdentifyingPatients for Care Management VideoCPC Pillars of Success: EngagingPatients and Caregivers in LongitudinalCare Management VideoCPC Pillars of Success: EpisodicCare Management VideoPersonalized Care Planning VideoPractices in Action (PIA) WebinarsPIA webinars are weekly 30-minute learningevents that deliver content on specific CPC topics and on small tests of change. Links toeach PIA webinar on risk stratification arelisted on the right.Action Group (AG) WebinarsAction Groups provide a deeper dive intospecific CPC change concepts and changetactics. Action Groups are three sessionslong, span a period of six weeks, andprovide an environment for practices tolearn, collaborate, and implement small testsof change over time. Links to each sessionon risk stratification are listed on the right.PIA #1What is 2-Step Risk Stratification andHow Does it Work?PIA#2Using Your Risk Stratification to TargetCare ManagementPIA #3Risk Stratification: Refining YourProcess Over TimePIA #13Skills for Care ManagementPIA #16Using Risk Stratification to PrioritizeCare Management ServicesPIA #36Assessing and Refining CM through theuse of DataAction Group 1(AG001) RiskStratification &Longitudinal CareManagement:AG001 Session 1AG001 Session 2AG001 Session 3Action Group 2(AG002) RiskStratification &Longitudinal CareManagement:AG002 Session 1AG002 Session 2AG002 Session 3Page 6 of 7
Resource CategoryResource TypeSession 2C: WhatNational Meeting 2018is Critical in CareThe 2018 National Meeting focused on thetheme of Advancing Patient-Centered Care. Management:Breakout sessions focused on populationhealth improvement and health equity,burden reduction, safer care and person andfamily engagement, among other topics.Practice SpotlightsPractice spotlights highlight the work ofCPC practices that are doing successfulwork in a specific change concept. Thefollowing spotlights are for risk stratification.CPC SpotlightsRisk StratificationResources Shared by CPC PracticesTools andThe following templates, guides, andAlgorithms:resources on risk stratification weredeveloped by practices and shared on CPC Connect.LinkSession 2C RecordingCPC Spotlight 1: Using RiskStratification to Target CareManagement ResourcesMercy Family Medicine Adult RiskStratification ToolSt. Bernard's Clopton Clinic's FourStratum Risk Stratification ToolVillage Primary Care's Five-StratumRisk Stratification ToolRisk Management Tool (Randy D.Walker MD)Risk StratificationWorkflows andProtocols:Risk Stratification Action Plan (CrystalLake Clinic)Risk Stratification Protocol (CrystalLake Clinic)Risk Management Process (Randy D.Walker MD)Longitudinal CareManagement:Traverse Bay Internal Medicine'sPatient-Oriented Action PlanPage 7 of 7
Risk Stratification and Longitudinal Care Management Learning and Action Summary This learning and action summary pulls together resources 1, videos . as you risk stratify patients in your practice. This guide provides content and resources that complement suggested implementation approaches provided in the . (Crystal Lake Clinic) Review .
