Health risk assessment and stratification in an integrated care scenario

Background: Health risk assessment and stratification have proven highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. 
Aim: The principal objective was to analyse five health-risk assessment strategies used in the five regions participating in the Advancing Care Coordination and TeleHealth Deployment (ACT) program (www.act-programme.eu): Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). A second aim was to explore the potential of population-based health risk predictive tools to contribute to risk prediction in the clinical setting.
Method: We characterized and compared risk assessment strategies among ACT regions by analysing operational risk predictive modelling tools for population-based stratification, as well as available health indicators. The risk assessment tool deployed in Catalonia (GMA, Adjusted Morbidity Groups) was used as an example to explore how population-based analysis can contribute to clinical risk prediction.
Results: The study indicated a high degree of conceptual agreement among the five ACT regions on the relevant role of population-based health risk assessment for regional deployment of integrated care. The entire ACT consortium shared its usefulness for service commission, case finding and screening. There was also consensus on the use of a population health approach as the optimal strategy for population-based risk assessment.

DOI: http://doi.org/10.5334/ijic.2870

Health risk assessment and stratification in an integrated care scenario.pdf