Q&A: Screening for high-risk patients

Q. How can case managers identify high-risk patients in a population health model?

A. The population health model requires a method of screening for high-risk and emerging-risk patients. There are many commercial and privately held high-risk screening tools available for at-risk patient. The case manager may administer a high-risk screen, or it may be administered by another healthcare provider. Certain screens are multidisciplinary so that each team member assesses risk within their discipline or profession to provide a comprehensive patient profile. The composite risk scores define the high-risk patients within the population health model.

The social worker is a key team member and may be the primary case manager for the high-risk patients within the population health model. This is because the social worker is instrumental in addressing the social determinants of poverty, food, and housing. The nurse case manager and social work case manager work well in tandem with high-risk patients.

For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.

Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.