– Risk Stratification –

Let our expert team collaborate with your healthcare organization on strategy to provide services to improve population health

Care Vitality - TCM (Transitional Care Management)

What is Risk Stratification?

Risk Stratification is a systematic process for identifying and predicting patient risk levels relating to health care needs, services, coordination and transitions of care. The goal of risk stratification is to identify those patients that are at the greatest risk and prioritizing the management pf their care to prevent uncontrollable costs and poor patient outcomes.

How can we help?

We collaborate on strategy and use our Patient Engagement Centers to provide services to the healthcare organizations at risk patient population

As value-based care delivery models—like Accountable Care organizations (ACOs), Patient Centered Medical Homes (PCMH) or Integrated Delivery Networks (IDNs) hoping to drive down costs and improve patient outcomes are now becoming more focused on managing population health and risk stratification becomes more important than ever. Healthcare organizations working to drive down their patient cost structure and improve outcomes must design interventions that target high-risk, high-cost patients who need to be managed carefully and proactively.

Risk Management in Healthcare Begins with Stratification

The foundational step of targeting these high-risk patients is, of course, to identify them. For example, ACOs have to be able to pinpoint which heart failure patients or diabetes patients are at high risk for readmission. Empowered with insight into their at risk patient population, our Patient Engagement Center assist healthcare organization by helping them manage these populations by; scheduling follow-up appointments, educate patients on their condition to promote literacy, medication reconciliation and adherence, care coordination and manage care transitions ultimately creating a continuum of care and improving patient outcomes while also driving down cost. The process of separating patient populations into high-risk, low-risk, and the ever-important rising-risk groups is called risk stratification. Providing services to support the healthcare organization to stratify patients according to risk and implement the support to the patients is key to the success of any population health management or risk stratification initiative.

Overview of Risk Stratification Methods

Several different methods are available for stratifying a population by risk. The following are some of the most common methods.

Hierarchical Condition Categories (HCCs): Part of the Medicare Advantage Program for CMS, HCC contains 70 condition categories selected from ICD codes and includes expected health expenditures.

Adjusted Clinical Groups (ACG): Developed at Johns Hopkins University,both inpatient and outpatient diagnoses to classify each patient into one of 93 ACG categories. It is commonly used to predict hospital utilization.

Elder Risk Assessment (ERA): For adults over 60, ERA uses age, status, number of hospital days over the prior two years, and selected comorbid medical illness to assign an index score to each patient.

Chronic Comorbidity Count (CCC): Based on the publicly available information from Agency for Healthcare Research and Quality (AHRQ)’s Clinical Classification Software, CCC is the total sum of selected comorbid conditions grouped into six categories.

Minnesota Tiering (MN): Based on Major Extended Diagnostic Groups (MEDCs), MN Tiering groups patients into one of five tiers from Tier 0 (Low: 0 Conditions), Tier 1 (Basic: 1 to 3), Tier 2 (Intermediate: 4 to 6), Tier 3 (Extended: 7 to 9), to Tier 4 (Complex: 10+ Conditions).

Charlson Comorbidity Measure: This method is explained in further detail below, but as a brief explanation, the Charlson model predicts the risk of one-year mortality for patients with a range of comorbid illnesses. Based on administrative data, the model uses the presence/absence of 17 comorbidity definitions and assigns patients a score from one to 20, with 20 being the more complex patients with multiple comorbid conditions. It is effective for predicting future poor outcomes.

Turnkey Services Offering


Identify patients based on follow-up care model

Identify available community and health resources


Obtain and review discharge information

Communicate with the patient or caregiver (by phone, e-mail, or in person)

Communicate with a home health agency or other community service that the patient needs


Educate the patient and/or caregiver to support self-management and activities of daily living

Provide assessment and support for treatment adherence and medication management

Educate the patient and/or caregiver


Facilitate access to services needed by the patient and/or caregivers

Review need of or follow-up on pending testing or treatment

Interact with other clinicians who will assume or resume care of the patient’s system-specific conditions

Establish or re-establish referrals for specialized care

Assist in scheduling follow-up with other health services