Abstract: Methods, systems, and computer-readable media are provided for identifying, stratifying, and prioritizing patients who are eligible for care management services. For each patient, patient health data is used to determine one or more of a disease burden associated with the patient, an amount of health system utilization by the patient, and an amount of money spent on healthcare services for the patient. It is further determined if the patient exceeds a respective threshold value associated with each of these criteria. If the patient exceeds the respective threshold value, the patient is stratified into a category comprising one of high-risk senior, high-risk adult, high-risk pediatrics, or high-risk maternity. The patient may also be prioritized based on one or more factors, and a notification may be sent to the patient informing the patient of his/her eligibility for care management services.

Abstract: Methods, systems, and computer-readable media are provided for identifying, stratifying, and prioritizing patients who are eligible for care management services. For each patient, patient health data is used to determine one or more of a disease burden associated with the patient, an amount of health system utilization by the patient, and an amount of money spent on healthcare services for the patient. It is further determined if the patient exceeds a respective threshold value associated with each of these criteria. If the patient exceeds the respective threshold value, the patient is stratified into a category comprising one of high-risk senior, high-risk adult, high-risk pediatrics, or high-risk maternity. The patient may also be prioritized based on one or more factors, and a notification may be sent to the patient informing the patient of his/her eligibility for care management services.

Abstract: Methods, systems, and computer-readable media are provided for identifying, stratifying, and prioritizing patients who are eligible for care management services. For each patient, patient health data is used to determine one or more of a disease burden associated with the patient, an amount of health system utilization by the patient, and an amount of money spent on healthcare services for the patient. It is further determined if the patient exceeds a respective threshold value associated with each of these criteria. If the patient exceeds the respective threshold value, the patient is stratified into a category comprising one of high-risk senior, high-risk adult, high-risk pediatrics, or high-risk maternity. The patient may also be prioritized based on one or more factors, and a notification may be sent to the patient informing the patient of his/her eligibility for care management services.

Abstract: A cloud-based system provides stratification of a medical population to facilitate the most efficient use of health intervention resources to improve the health of individual patients. The system can stratify coarse cohorts to identify patients with high management risk and/or high impactability. The system can recommend health service workflows for a particular patient. The system can use medical, community, and social data to better identify health service workflows appropriate for an individual and avoid missed opportunities to improve the health of highly impactable patients.

Abstract: Methods, systems, and computer-readable media are provided for identifying, stratifying, and prioritizing patients who are eligible for care management services. For each patient, patient health data is used to determine one or more of a disease burden associated with the patient, an amount of health system utilization by the patient, and an amount of money spent on healthcare services for the patient. It is further determined if the patient exceeds a respective threshold value associated with each of these criteria. If the patient exceeds the respective threshold value, the patient is stratified into a category comprising one of high-risk senior, high-risk adult, high-risk pediatrics, or high-risk maternity. The patient may also be prioritized based on one or more factors, and a notification may be sent to the patient informing the patient of his/her eligibility for care management services.