Preventing Chronic Disease in the Rising-Risk Population: Three Strategies for ACOs Before, During, and After the Patient Engages in the Clinical Care Setting

In this paper, “Preventing Chronic Disease in the Rising-Risk Population: Three Strategies for ACOs Before, During, and After the Patient Engages in the Clinical Care Setting,” the American Medical Association (AMA) and Leavitt Partners offer strategies for health care organizations working within an alternative payment model to target the rising-risk population. These recommendations include:

  • Identifying the rising-risk index of patients.
  • Rethinking care strategies to address non-clinical factors that affect clinical outcomes, such as social determinants of health.
  • Connect rising-risk patients to behavioral and lifestyle change support groups.

The paper supports the theory that effectively identifying and addressing the health needs of the rising-risk population will lead to overall population health gains.