What is a high risk patient?

“What’s a high-risk patient?” asked our newly hired care coordinator.

Interesting question, and, as you would expect, one without an easy answer.

One of our patient-centered medical home certifying agencies was performing an audit for recertification, and requested information on our high-risk patient registry, including how patients were identified and assigned to the registry.

When you ask doctors or any other providers, we all know one when we see one. Complex medical problems that require us to pour enormous amounts of time into trying to get patients healthy. “Frequent fliers.” “Noncompliant” patients. Endless comorbidities. Polypharmacy. Low health literacy. The list goes on and on.

But having any or all of these things does not automatically make someone high risk. There is so much more to it than that.

When it comes down to it, defining a patient as “high risk” becomes very tricky, gets us into foreign territory, even into dangerously politically incorrect territory.

Think of all the potential definitions, all the multiple variables, all of the different ways of looking at each individual patient, and what might end up getting us to think of them as being “high risk.”

Age. Length of problem list. Number of medications. Number of specialists and subspecialists they see. Number of appointments, no-show rate. Somatic complaints, underlying psychiatric disease, excessive imaging and testing.

Under the current patient-centered medical home paradigm, being labeled a high-risk patient is an advantage. Lots of resources will be poured into your care. People will be calling you at home all the time, helping make sure you take your medicines, get your tests done, see your specialists, come back for follow-up.

But who would want to be labeled high risk?

Reminds me of the old Seinfeld episode where Elaine was labeled a “difficult patient,” had that notation added to her chart, and was unable to escape that stigma throughout the health care system in New York City.

We need to figure out how to engage our patients and their providers in a discussion, in open communication and engagement to get everyone we are worried about to agree that they should be enrolled in a “high-risk registry.” Call it what you will, we are only saying that they need us even more than they know.

We do not want to look back and have some exposé where patients discover they have been labeled, somehow stigmatized, or discriminated against.

Maybe it will all just come down to a gestalt, the sense of how we feel, what is best for the patients. And clearly an open and frank discussion with patients that there is nothing derogatory about this label, that it is given with their best interests in mind.

Or maybe it will be a set formula: age x creatinine + weight in kilograms x zip code + the sum of their ICD-9 codes squared ÷ the number of phone calls in the past 6 months.

Hey, maybe we’re on to something here …

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home

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  • southerndoc1

    “Maybe it will all just come down to a gestalt, the sense of how we feel, what is best for the patients”

    Or maybe it will all just not be worth doing . . .

  • Thomas D Guastavino

    The interesting question here is high risk for whom? In the past the answers were easier. Take the example of the 25 year old, uninsured drug addicted patient that gets hit by a car and suffers a complex open tibia fracture and gets an attorney. The patient is at risk due to the complex and unpredictable nature of the injury sustained. The hospital is financially at risk for the high cost of the treatment. The surgeon is at risk for limited compensation for time spent, inherent liability of the procedure and now has to deal with a potential additional hit to future income risk due to potential lower quality score due to,not only the inherent complexity of the injury, but the prolonged treatment because of high secondary gain.
    For providers the answer is clear. Stay away from “high risk” patients.