1. Identify specific individuals within your chosen population using multiple approaches.
  2. Develop real-time patient identification methods.

1. Identify specific individuals within your chosen population using multiple approaches.

Below is guidance on how to begin using data to identify individuals and questions to discuss with primary care physicians who see patients in your population segment.

Generate a list of patients who fit the description of your chosen population segment, using at least two of the following methods.
Meet with primary care clinicians to review the list of patients who are in the population segment with complex needs and high costs.
Marry what you learned in Step 1 with what you learned from primary care physicians.

Here are a variety of ways to identify potential patients. Remember, it is best to use a combination of quantitative and qualitative approaches – ideally, three of the following six methods.

Quantitative approaches
Use clinical information systems to identify individuals (e.g., diagnosis flags).
Create a utilization threshold to identify patients with a certain number of visits to the emergency department or inpatient stays in the past year.
Use a predictive model.
Qualitative approaches
Ask primary care providers to refer their patients to your enhanced program.
Ask patients to rate their health status, identifying those who rate their health as fair or poor.
Use a qualitative threshold based on an understanding of the level of self-efficacy, life trauma, or life conditions (e.g. poverty, social support, cognitive function).
Tips and guidance for identifying patients who are a good fit for your program:


2. Develop real-time patient identification methods.

Establish a process for event notification from the emergency department, hospital, or other community organizations.
Using PDSA cycles, test using a triage coordinator to find appropriate individuals by reviewing up-to-date patient information, including:
Support primary care and other providers to make appropriate referrals in real time on a week-to-week basis.
Tips and guidance for real-time patient identification methods:
  • Develop methods to identify potential patients at opportune times, such as during a hospitalization or ED visit, when their motivation to participate in enhanced programming maybe higher than usual.
  • Co-locating care management staff of community health clinics, behavioral health clinics, and social service organizations in the hospital can be an effective way to identify potential patients, and is a practical and constructive way of collaborating across different organizations.
  • Create coordinated, responsive, and easy communication methods between those who refer patients and care management staff.
  • Partner with another organization that serves a high volume of your chosen population segment. Partnership methods around patient identification can be as simple as patient referral, or as sophisticated as developing a shared medical record to quickly identify individuals for the enhanced care program.


“The Camden Coalition has tiered the problem at two different levels. We have a model of care for the most extreme patients, the outliers, and then a model of care for the next tier down of hospitalized patients. We are focused on hospitalized patients or patients using the emergency room. Both tiers are data driven. Every morning we wake up with a list of folks from the Health Information Exchange, a regional list, so we know how often they’ve been back in the last couple of years and the last six months. Anyone with two or more admissions in six months, with medical and social and behavioral complexity, is eligible for the higher tier, high utilizer intervention, and anyone with one admission or emergency room use is eligible for the next tier down. We don’t take referrals from anyone so the entire intervention is data-driven, coming from these lists every morning. We have a full-time team up in the hospital, and every morning they wake up with the list and they go right to the bedside, enroll patients, and offer the opportunity to enroll. Our interventions right now are being studied, so this is a randomized control trial. The care managers consent the patient, walk out, randomize them, and then walk in and let them know if they’ve been enrolled. If they get enrolled, it’s a 90 to 100-day intervention, intense, wrap-around case management. It looks a lot like programs such as an ACT team or a PACE program.”Jeffrey Brenner, MD, Executive Director, Camden Coalition of Healthcare Providers