Health systems must take a three-step approach to rising-risk patient management. First, they must identify their at-risk populations. Second, they must use existing resources to maximize scale. Finally, they must enhance primary care to sustain the health care system.

Based on learnings from progressive health care organizations from around the globe, this research report makes the case for devoting limited resources to rising-risk patient management, while providing imperatives for developing an actionable rising-risk patient management strategy.

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The case for rising-risk management

As systems around the world continue to embrace population health management, many health care leaders have focused their immediate attention and limited resources on creating a care management infrastructure for their high-risk patients. While high-risk patient management is a necessary first step in any successful population health strategy, a strict focus on high-risk patients alone is insufficient.

To cope with overwhelming patient demand and rising costs in the long term, health systems must shift their focus and target their resources to patients on the cusp of risk escalation. Management of future high-risk patients—or "rising-risk patients"—is a health system's greatest opportunity for ensuring sustainability in an increasingly tumultuous health care landscape.

Read more about this opportunity on p. 9 of the research report.

Identifying your at-risk populations

Before hospitals and health systems can effectively manage their rising-risk patients, they must first find and identify them. Health systems can, and should, start to leverage the data sources that they already have easily available to them.

Meanwhile, to proactively identify rising-risk patients who have not recently used the health care system, health systems must extend their reach via community partners that regularly interact with these rising-risk patients. Finally, health systems must ensure that their identification work is tailored to their local context, based on population demographics and services available within their catchment area.

Read more about identifying your at-risk population on p. 24 of the research report.

Using your existing resources to maximize scale

In addition to one or two comorbidities, rising-risk patients often have underlying psychosocial conditions that confound and complicate their clinical care. To maintain stability, it is crucial that rising-risk patients are connected to social services that exist in the health care continuum.

First, health systems must ensure that their providers are fully aware of the wide range of both social and clinical services that are already available to them. Next, they must facilitate connections between social and clinical care silos for their rising-risk patients.

In addition to tackling these barriers, health systems should turn to patients themselves as a scalable (and untapped) resource for promoting long-term self-management.

Read more about using your existing resources on p. 38 of the research report.

Enhancing primary care to sustain the system

Though hospitals have a huge stake in the success of rising-risk patient management, they may not be the best setting for managing rising-risk patients. In an ideal system, sustained management of rising-risk patients would exist entirely under the purview of comprehensive primary care services.

However, overburdened and under-resourced primary care providers are often not fully equipped to meet the needs of rising-risk patients. Successful organizations will not be afraid to think creatively about potential partners, both clinical and non-clinical, that may serve as critical support for rising-risk patient management.

Read more about enhancing primary care on p.52 of the research report.

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