Implementing Risk Stratification in Primary Care: Challenges and Strategies

J Am Board Fam Med. 2019 Jul-Aug;32(4):585-595. doi: 10.3122/jabfm.2019.04.180341.


Introduction: Primary care risk stratification (RS) has been shown to help practices better understand their patient populations' needs and may improve health outcomes and reduce expenditures by targeting and tailoring care to high-need patients. This study aims to understand key considerations practices faced and practice experiences as they began to implement RS models.

Methods: We conducted semistructured interviews about experiences in RS with 34 stakeholders from 15 primary care practices in Oregon and Colorado and qualitatively analyzed the data.

Results: Three decisions were important in shaping practices' experiences with RS: choosing established versus self-created algorithms or heuristics, clinical intuition, or a combination; selecting mechanisms for assigning risk scores; determining how to integrate RS approaches into care delivery. Practices using clinical intuition found stratification time-consuming and difficult to incorporate into existing workflows, but trusted risk scores more than those using algorithms. Trust in risk scores was influenced by data extraction capabilities; practices often lacked sufficient data to calculate their perceived optimal risk score. Displaying the scores to the care team was a major issue. Finally, obtaining buy-in from care team members was challenging, requiring repeated cycles of improvement and workflow integration.

Discussion: Practices used iterative approaches to RS implementation. As a result, procedural and algorithmic changes were introduced and were influenced by practices' health IT, staffing, and resource capacities. Practices were most successful when able to make iterative changes to their approaches, incorporated both automation and human process in RS, educated staff on the importance of RS, and had readily accessible risk scores.

Keywords: Chronic Disease; Colorado; Disease Management; Electronic Health Records; Health Expenditures; Information Technology; Medical Informatics; Oregon; Primary Health Care; Qualitative Research; Risk Adjustment; Surveys and Questionnaires; Workflow.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Colorado
  • Delivery of Health Care, Integrated / organization & administration*
  • Delivery of Health Care, Integrated / statistics & numerical data
  • Electronic Health Records / statistics & numerical data
  • Health Plan Implementation / organization & administration*
  • Health Services Needs and Demand*
  • Humans
  • Oregon
  • Primary Health Care / organization & administration*
  • Primary Health Care / statistics & numerical data
  • Qualitative Research
  • Risk Assessment / methods
  • Risk Assessment / statistics & numerical data
  • Surveys and Questionnaires / statistics & numerical data
  • Workflow