A small fraction of patients drive the vast majority of health care spending.

That’s why many primary care practices have started using tools to identify adults most at risk of ending up in the hospital or emergency department or needing high-cost specialty care.  Higher risk patients receive individualized care plans and customized resources, such as additional contacts or visits to manage their chronic disease.

Now, Common Ground Health is working with a California group to test a similar risk stratification screening for children. The goal is to focus additional resources on children with complex conditions such as asthma, developmental disabilities or food insecurity—conditions that when treated effectively can often be managed without expensive and disruptive hospitalizations.

Locally, practices with pediatric patients are needed to pilot the tool for at least a month and fill out a survey on the screening’s effectiveness.

 “The risk stratification process helps practices become more efficient with their resources, targeting more intensive services towards patients who need it the most,” said Dr. Thomas Mahoney, chief medical officer of Common Ground Health.

The evaluation is relatively simple: A member of the care team completes a three-question questionnaire with patients to determine if they have visited the emergency department or been admitted to the hospital in the past six months, or if they are under the care of a specialist. If so, patients are given a secondary screening to identify clinical, physical or social factors that might lead to repeat hospitalizations.  

Patients identified to be at high risk would work with the practice’s care manager or care team individually to help them manage their conditions. Patients at medium or rising risk would work with the practice’s care team and be provided education and instruction about their illness.

To test the validity of the approach more widely, Common Ground Health is partnering with Pediatric Practices Practice Transformation Network in Southwestern California. The network is piloting the tool in some of its 237 medical practices, which provide care for more than 1.5 million children.

“Assuming the approach proves effective, we’re hoping practices will continue to use risk stratification as an important way to identify high risk patients and interventions to better connect with children with multiple risk factors,” said Brenda Chapman, quality improvement clinical coordinator for Common Ground Health.

Connecting vulnerable patients with care management has already shown great dividends locally. Half of all patients who worked with care managers in the Finger Lakes region as part of a 2012-2015 practice transformation study experienced a decline in hospital admissions, and many experienced marked improvement in the management of chronic diseases.

To enroll in the pediatric risk stratification pilot, or to learn more about practice transformation, contact William Brien, director of practice transformation at Common Ground Health, at 585-224-3149 or