According to the CDC, 90% of the nation’s $4.5T in annual health care expenditures are for chronic and mental health conditions. One approach to managing these chronic conditions is to proactively identify patients at risk for inappropriate ED utilization, avoidable readmissions and adverse events.

WakeMed Health & Hospitals, Christiana Care Health System and Big Sky Care Connect—Health Catalyst clients—used risk stratification models, in combination with care coordination teams, to identify and engage patients. Ms. Chambers discusses implementation of these models, as well as best practices, pitfalls to avoid and future opportunities.