title: Aligning population-based care management with chronic disease complexity.
abstract: 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.
authors.affiliation: University at Buffalo, State University of New York, School of Nursing, Buffalo, NY. Electronic address: hewner@buffalo.edu.
authors.forename: Sharon
authors.initials: S
authors.lastname: Hewner
authors.affiliation: University at Buffalo, State University of New York, School of Nursing, Buffalo, NY.
authors.forename: Jin Young
authors.initials: JY
authors.lastname: Seo
authors.affiliation: University at Buffalo, State University of New York, School of Nursing, Buffalo, NY.
authors.forename: Sandra E
authors.initials: SE
authors.lastname: Gothard
authors.affiliation: Elmwood Health Center, Buffalo, NY.
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: Johnson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease / Q000451:nursing*; D015331:Cohort Studies; D018672:Community Health Planning / Q000458:organization & administration*; D015897:Comorbidity; D005260:Female; D059033:For-Profit Insurance Plans; D006296:Health Services / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration*; D008484:Medicaid; D006278:Medicare; D008875:Middle Aged; D009511:New England; D009732:Nursing Care / Q000458:organization & administration*; D009937:Organizational Objectives; D011320:Primary Health Care / Q000458:organization & administration*; D012307:Risk Factors; D014481:United States; D055815:Young Adult
keywords: Chronic disease complexity; Hospitalization rates; Informatics; Insurance; Nursing care; Population health; Primary care; Readmissions; Risk-stratified care management