Beyond Risk Scores: Driving Results through Integrated Clinical and Operational Workflows

In value-based care, patient risk stratification is often the starting point for optimizing care and improving outcomes. However, it's essential to go beyond merely identifying high-risk patients. Below, we outline four key steps in integrating risk stratification into operations, highlighting the challenges and what we've learned through our experience.

1. Identifying High-Risk Patients

From our experience, identifying high-risk patients is typically the most straightforward part of this process. Many healthcare organizations can achieve this in-house, or they can purchase predictive models and risk stratification services from various vendors. While it's a foundational step, this alone doesn’t lead to meaningful change unless it’s followed up with concrete actions. The real challenge lies in what comes next: integrating those insights into clinical operations and ensuring that high-risk patients receive appropriate care (1)(2). Most organizations stop at this point, but we've always pushed further.

2. Incorporating Risk Insights into Clinical Workflows

This is where things get slightly more complex, but it's still very achievable with the right tools and integrations. At this stage, organizations with internal IT teams or external vendors to ensure that the data from risk stratification models is surfaced within the clinician’s workflow. This could involve embedding data directly into the EHR or building custom tools that integrate with other systems. It requires close collaboration with IT, but with the right team, it's doable (3). Many organizations can reach this point, but it’s only when risk insights are fully integrated into clinical decision-making processes that they become truly actionable.

3. Optimizing Care Pathways and Engaging Operational Teams

Here is where we start to see the real challenge—and also where many organizations struggle. In our past projects, we found that moving from risk identification to optimized scheduling and care pathways requires deep collaboration between clinical and operational teams. It’s not enough for a doctor to note that a patient is high-risk; this information must reach the operations team so they can prioritize these patients for follow-ups and care coordination. This step often requires more sophisticated tools that bridge clinical workflows with operational workflows (4). The challenge is integrating these two sides in a way that ensures both the clinician and operational team are working from the same playbook, something we’ve successfully managed in previous implementations.

4. Monitoring at the Population Level

This step is often the most neglected, but from our experience, it’s essential for long-term success. Many organizations don’t have the infrastructure to monitor high-risk patients at the population level. We’ve built dashboards and systems that allow clinical leaders to track trends, monitor outcomes, and intervene as needed. This allows the organization to determine whether clinical interventions are effective or whether operational issues are causing gaps in care(5)(6). Population-level monitoring not only ensures that care is continually optimized but also gives leadership the data they need to make strategic decisions that improve outcomes across the board.

Conclusion

Experience has shown us that true value lies in moving beyond simply identifying high-risk patients to deeply integrating those insights across the care process. This requires bridging clinical and operational efforts, enabling teams to take timely, coordinated actions. By ensuring that risk insights drive real-world decisions—from individual patient care to population-level outcomes—organizations can achieve measurable improvements in both patient care and operational efficiency.