Table 2 Stratification tools and interventions

Mateo Abad 2020 [18]

Integrated care organizations (ICO) within the Basque Country health system, Spain.

Basque population-based algorithm

The intervention was the CareWell integrated care model, which included: coordination between health providers, home-based care, patient empowerment, and support from ICT tools. The CareWell model defined a specific care pathway with several phases, focusing on care coordination/communication and patient empowerment/home-based care. The CareWell model for multimorbidity patients includes identification through the Basque population-based risk stratification (Complexity defined as having a predictive risk index higher than 6.28, which means that the probability of using the health services in the following year was at least 6.28 times higher than for an average Basque citizen), baseline assessment, therapeutic plan, follow-up, patient stabilization, integrated care during hospitalization, coordinated discharge. It also included a patient empowerment program called KronikOn, with 4 sessions of 20–30 min provided by nurses.

9–12 months

Snooks 2018 [17]

General practices within Abertawe Bro Morgannwg University Health Board

PRISM software

The intervention consisted of: (1) PRISM software that provided risk scores for individual patients, (2) 2 h of practice-based training on using the PRISM software, (3) clinical support through 2 “GP champions”, (4) technical support through a “help desk”, and (5) a user-friendly handbook. The intervention was provided to general practitioners, not directly to individual patients. PRISM software estimates emergency admission risk. Practices use risk scores to target services.

1–12 months

Lugo Palacios 2019 [20]

Heywood Middleton and Rochdale Clinical Commissioning Group (HMR CCG)

HMR CCG Long Term Conditions Test Bed

The interventions were:

1. Clinical audit and population management software including risk algorithms (MSDi Optimise). The algorithm provided prediction scores about patients’ risk of developing long-term conditions (COPD, heart failure, type 2 diabetes) at 12 and 24 months.

2. Quality improvement program (Evidence into Practice) for COPD and diabetes, delivered over 12 months

3. Remote telehealth monitoring and coaching service (Closercare) for patients with heart failure or COPD, involving 12 weeks of remote monitoring followed by 6 weeks of weekly 60-minute coaching sessions

12 months

Jiao 2015 [21]

Hong Kong Hospital Authority

RAMP-DM

The intervention is the RAMP-DM program, which involves comprehensive risk factor screening, risk stratification (RAMP-DM provides comprehensive risk screening for diabetes-related complications, with patients stratified into risk groups), and provision of appropriate interventions and education by a multidisciplinary team based on the patient’s risk level and HbA1c level. The frequency of the full risk factor screening and assessment varies, with some patients receiving it annually and others every 2–3 years with annual blood tests. Care is managed by trained nurses, including education and lifestyle advice.

Aug 2009 - Jul 2013

Wan 2018 [22]

Hong Kong Hospital Authority

RAMP-DM

The intervention is the Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM), which involves: (1) risk assessment and stratification by nurses, (2) multidisciplinary care coordinated by a nurse manager, (3) individualized care planning based on risk factors, and (4) patient education and lifestyle advice provided by nurses. The RAMP-DM is provided in addition to usual care by the patient’s general outpatient clinic doctor.

Aug 2009 - Nov 2015

Gupta 2019 [23]

University of California Los Angeles Health (UCLA Health)

Population Health Value (PHV)

PHV model identifies spending reasons and creates care pathways. Larger lower-risk cohorts receive fewer intensive interventions, smaller higher-risk cohorts receive more intensive interventions, based on data analytics.

The interventions included:

- For dementia patients:

- Dementia education using patient portals and online materials for low-risk patients (tiers 4 and 5)

- Referral to the Alzheimer’s and Dementia Care (ADC) program, which provided nurse practitioner co-management of dementia care, for middle-risk patients (tiers 2 and 3)

- Intensive care management for high-risk patients (tier 1) to coordinate care across primary and specialty teams, reduce utilization, and initiate palliative care

- For CKD patients:

- Hiring a CKD care coordinator to expedite ambulatory care and increase access to interventional radiology services, who coordinated with extensivist primary care physicians managing high-risk patients (tier 1)

- For cancer patients:

- Three care pathways defined for five risk tiers, but details not provided

Aug-Sep 2016 & Apr-May 2017

Soto-Gordoa 2019 [19]

Basque Department of Health

Adapted ACG system

The intervention consisted of a chronic-care program with multidisciplinary teams, new roles like liaison nurse and case manager, an infrastructure of information and communications technologies, and telehealth/empowerment services including BetiOn, Active Patient, and Osarean. Prioritization based on hospitalization history and risk score using the ACG system. The aim is to reduce hospital inpatient services by empowering primary care services.

1 year (2014)