Healthcare Performance Benchmarks
Healthcare Performance Benchmarks
May 29, 2013Vol. III Issue 22

High-Risk Patient Roster in
Atrius Health Geriatric Care Model

High-Risk Patient Roster in Atrius Health Geriatric Care Model This Week's Challenge: By applying an "ACO magnifying glass" to high-risk patients and high-cost events, and using an organizational background in rapid cycle improvement, Atrius Health's focused interventions hit Triple Aim goals within its Medicare's Pioneer ACO model. We wanted to share Atrius Health's roster review of high-risk patients.

Click here to view a printable version of the table.

What We Learned: "In our redesign of our geriatric care model to meet care gaps, we have developed a ‘high-risk roster review’, a multi-disciplinary team review of the highest risk patients. We used a new risk stratification tool to identify our high-risk patients. Those patients go on a roster that in the primary care practice is reviewed by a multidisciplinary team to achieve outcomes. A roster helps the team see metrics: for example, have we documented patients’ advance directives? Do we know what patients want for care at the end of life? What are the gaps? It helps the team address those gaps."

— Emily Brower, executive director of accountable care programs at Atrius Health.

Showcase your data in Healthcare Performance Benchmarks. If you have a healthcare chart you'd like to share, contact the Healthcare Intelligence Network at or toll-free at 888-446-3530.

Missed last week's chart? View Greatest Challenges of mHealth.

Join our Online Communities: Twitter Facebook LinkedIn YouTube Pinterest

Take this month's e-survey: Telehealth in 2013.

Interested in all open surveys? Review them here.

Download new market research: PCMHs in 2012.

HINfographic: ACO Activity Assessment Tracks Launch of Accountable Care Organizations.

Read related blog post: High-Risk Patient Roster Helps Atrius Pioneer ACO ‘Beat the Benchmark’.

Share this data with colleagues on:

Medicare Pioneer ACO: Case Study on Atrius Health's Focus on the Triple Aim

Excerpted from Medicare Pioneer ACO: Case Study on Atrius Health's Focus on the Triple Aim, a 45-minute webinar, during which Emily Brower shared the first year lessons from Atrius Health's experience as a Medicare Pioneer ACO and how the program is evolving in year two.

© 2013 Healthcare Performance Benchmarks by Healthcare Intelligence Network.
Editor: Jessica Fornarotto,;
Publisher: Melanie Matthews,

Healthcare Intelligence Network, 800 State Highway 71, Suite 2,
Sea Girt, NJ 08750 | 888-446-3530 |