Care Transformation Center Blog

5 easy steps to improve PCP engagement of high-risk patients

by Darby Sullivan

Effective high-risk care management is built on the foundation of activating patients in primary care. But adding high-risk care management to an already demanding workload can fuel already high levels of burnout—a major concern, given that 45% of primary care physicians say they would quit if they could afford to.

Even the most advanced organizations struggle with the logistics of attributing high-risk patients to specific primary care clinics.

So how do you get PCPs to play an active role in high-risk patient care management without adding more their 'to-do' list? We've compiled five best practices to consider when devising your strategy:

1. Have physicians review high-risk patients identified in the risk stratification process

Williams Healthcare (pseudonym)—a safety-net health system in a major Western city—supplements stratification analytics (e.g., inpatient admissions, ED visits, and number of chronic conditions) with physician input in order to enroll complex patients in intensive care management at one of three specialized high-risk clinics. That helps ensure that patients are treated with the most appropriate resources and, by having physicians review the list of patients produced by analytics, encourages buy-in from the start.

Using this approach, Williams Healthcare raised patient enrollment in high-risk clinics from 25% to 75%.

2. Use the care management team to enable top-of-license care

Arizona Connected Care, a Tucson ACO that includes TMC Healthcare and more than 350 affiliated physicians, added two non-clinical full-time staff to their care management team to identify readmission avoidance opportunities. The team, which consists of a medical assistant and a social worker, uses an analytics platform to match high-risk patients with affiliated primary care clinics based on site capabilities. In addition, staff are able to identify which practices lack comprehensive care management programs. This capability allows the team's clinical staff to provide longitudinal support for patients assigned to such practices, offloading the task from PCPs.

By using each member of the care management team at top-of-license, Arizona Connected Care reduced readmission rates of patients discharged to post-acute care by 50%.

3. Match physician compensation with high-acuity patient panels

Robinson Health (pseudonym), a coordinated care plan focused on Medicare Advantage products, runs multiple primary care medical home clinics across the southern United States. Using a value-based model, Robinson Health compensates providers based on the complexity of their patient panel to avoid burnout and foster buy-in. Since Medicare reimburses on a risk-adjusted basis for Medicare Advantage plans, high-acuity patient panels become financially attractive for providers.

4. Recruit providers that fit culturally and have the right experience

Iora Health, a four-clinic nationwide system, prioritizes recruiting staff who believe in patient-centered, holistic care for high-risk patients. Iora recruits PCPs who are able to problem-solve from a systemic perspective and have experience in population health management, including managing a care team and fostering a positive team culture. Staff must also be a cultural fit, especially health coaches who interact closely with clinicians and patients.

By using the best care team at their disposable, one Iora clinic saw a 40% decrease in hospital admissions, a 40% decrease in ED visits, and a 25% decrease in surgeries.

5. Develop patient engagement tactics to accommodate diverse population needs

In order to be effective, health systems must forgo a generic approach to patient engagement and instead pursue  individualized support based on factors such as age, socioeconomic status, and native language. Across groups of patients, best practices include automated calls, patient portals, home visits, e-visits, and daily check-in calls from care managers. To build stronger relationships with patients and develop that individualized approach, providers use techniques such as motivational interviewing and shared decision making.

While provider organizations use many models of high-risk patient attribution, the most successful approaches incorporate these five best practices to support the care team, activate patients, and achieve measureable results.

If you're interested in additional details about each of these case studies, email Darby Sullivan at

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