How to Identify High Risk Patients

The foundational step of targeting these high risk patients is to first identify them.  There are several warning signs that can help you evaluate who the high risk patients are.  Defining the high risk patient can be a bit tricky since different specialties have different views on what it means to be “high risk”. Here are some key factors to help you identify which patients are at high risk:

  • Prior hospitalization in the last year
  • Behavioral health conditions
  • Noncompliant
  • Poor social support
  • Financial barriers to health access
  • Frequent visits to the ER in the past six months
  • At least one complex illness
  • Multiple comorbities

When you are armed with this knowledge, clinicians are then able to schedule follow-up appointments and ensure that those patients understand their medication and all other aspects of the care plan.  

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High Risk Patients

The top 5 percent of patients require high intensity, one to one care management.  High risk patients may have comorbidities that require more complex coordination across the continuum of care.  The following steps can help manage high risk patients and keep them out of the emergency room:

  • Schedule office visits to proactively address chronic conditions
  • Always educate the patient and caregivers on disease-specific warning signs
  • Simplify the medication schedule and perform regular medication reconciliation
  • Know the details about the patient not commonly captured in used risk algorithms:  their social support network, living situation and ability to follow through with personal health goals
  • Take a patient-centered approach to improve the overall patient experience, build trust and improve engagement
  • Optimize your time with patients

What it boils down to is that higher risk patients require higher level caregiver collaboration.  It demands that the healthcare team does everything it normally does—only better.  

Customers of HybridChart have significantly reduce their readmission penalties. One customer was able to reduce hospital readmission rates to 1/3 that of the national average!  Ready to reduce yours? 


Dr. Gregory Sanders is a Harvard-trained, practicing cardiologist and founder and CEO of HybridChart. He has been coding since the 1980s and has spent his medical career focusing on improving processes. His patient care skills earned him recognition as one of Phoenix Magazine’s TOP DOCs. He lives in Scottsdale with his family.