02 — Capability · BC-1860.10
Population Risk & Attribution
Know which patients or members are likely to need more care, cost more or fall through gaps, by combining claims, clinical and social data into attribution, risk tiers and care gap lists that teams can act on. Building predictive models in general is analytics.
- Risk Stratification
- Risk Tiering
- Population Segmentation
In scope
- Patient attribution and panel assignment
- Risk scoring and tiering, including member health risk assessments
- Care gap and rising-risk identification
- Condition and program registries
Out of scope
- Predictive modeling and data science in general (see BC-750.60)
- Customer segmentation for marketing (see BC-410.30)
- Risk adjustment documentation (see BC-1860.30)
Realized by · 6
- Epic · Payer-Provider Exchangepartial via BC-1860.10.30
- Epic · Healthy Planetstrong via BC-1860.10.10
- Oracle Health · Health Data Intelligencestrong via BC-1860.10.30
- MEDITECH Expanse · Population Health and Care Compassstrong via BC-1860.10.30
- InterSystems HealthShare · Event Notificationsstrong via BC-1860.10.30
- InterSystems HealthShare · Health Insightpartial via BC-1860.10.20
Used in · 2
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 4
- BC-1860.10.10Patient AttributionAssign each patient or member to the clinician, practice or contract accountable for them, using visits, claims and payer rosters, and settle disputed assignments.
- BC-1860.10.20Population Risk ScoresScore each person's likelihood of high cost, hospital use or decline from claims, clinical and social data and self-reported health risk assessments, and refresh scores as new data arrives.
- BC-1860.10.30Care Gap DetectionFind preventive screenings, chronic condition checks and follow-ups each person is due for but has not had, and route them to the team that will close them.
- BC-1860.10.40Population RegistriesKeep condition and program registries that show every person in a group, their status and their open needs, for care teams to work from.