Aligning population-based care management with chronic disease complexity

Background: Risk-stratified care management requires knowledge of the complexity of chronic disease and comorbidity, information that is often not readily available in the primary care setting. The purpose of this article was to describe a population-based approach to risk-stratified care management that could be applied in primary care. Methods: Three populations (Medicaid, Medicare, and privately insured) at a regional health plan were divided into risk-stratified cohorts based on chronic disease and complexity, and utilization was compared before and after the implementation of population-specific care management teams of nurses. Results: Risk-stratified care management was associated with reductions in hospitalization rates in all three populations, but the opportunities to avoid admissions were different. Conclusions: Knowledge of population complexity is critical to the development of risk-stratified care management in primary care, and a complexity matrix can help nurses identify gaps in care and align interventions to cohort and population needs.