To cope with overwhelming patient demand, increasing quality standards, and rising costs in the long term, health systems must expand the focus and target their resources to patients on the cusp of risk escalation. That's because one in five rising-risk patients escalate into high-risk each year. So under risk-based contracts, management of rising-risk patients is a health system's greatest opportunity for ensuring sustainability in today's health care landscape. However, that's easier said than done.

To do it well, leading organizations ensure that strategic resources are largely allocated at the intersection of primary care and chronic disease management to curb cost and demand. They target rising-risk management efforts based on key patient risk factors across four, high-level steps:

1. Refresh your strategy to identify at-risk patients every one-to-two years

In order to run targeted rising-risk interventions, population health leaders start with data analytics to identify their at-risk patient population, then build a system around these patients.

2. Use the medical home as the epicenter of patient management

The sheer number of rising-risk patients (up to 35% of your patient population) will require organizations to develop and implement lean, scalable interventions that build on the primary care team at its core.

3. Focus patient education on building self-management skills

Effective patient self-management in-between primary care appointments can reduce the risk of patient escalation and avoidable acute care utilization.

4. Engage community organizations to fill care gaps surfaced in the community health needs assessment

Partnerships among health systems, public health bodies, and community organizations are the most effective ways to sustainably address rising-risk patients' social and community needs.