Risk watchlist: monitoring high-risk patients
Use the risk watchlist to identify and manage high-risk patients.
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- riskwatchlistpopulation-health
The Risk Watchlist surfaces patients who may need intervention based on risk scores, recent events, and care gaps. This article explains how risk is calculated, how to use the watchlist, and how to document interventions.
What is the risk watchlist?
The watchlist (App → Risk watchlist) shows patients flagged as high-risk. Risk is calculated from multiple signals: recent ED visits, hospital admissions, missed appointments, overdue screenings, abnormal vitals, high PHQ-9 scores, and social determinants. Each patient has a risk score (0-100) and a risk level (low, medium, high, critical).
Understanding risk scores
Scores are recalculated nightly. Factors include: Age and comorbidities (30%), Recent utilization (25%), Care gaps (20%), Behavioral health (15%), Social factors (10%). A score > 70 is high risk; > 85 is critical. Scores are estimates, not diagnoses — use clinical judgment.
Using the watchlist
The watchlist shows patient name, risk score, risk level, primary provider, and top risk factors. Filter by provider, risk level, or risk factor. Sort by score (highest first) or by "days since last touch" (patients you haven't seen in a while). Click a patient to open their chart.
Risk factors
Common risk factors: "3 ED visits in 90 days", "PHQ-9 score 18 (moderately severe)", "HbA1c > 9%", "Missed last 2 appointments", "No PCP visit in 12 months", "Food insecurity indicated". Each factor has a weight. You can see the full breakdown in the patient chart under Risk.
Documenting interventions
When you intervene (call patient, schedule appointment, care management referral), document it in the Risk section of the patient chart. Click "Add intervention", select type, and add notes. Interventions are tracked and affect the risk score over time. The watchlist shows "Last intervention" so you know who's been contacted recently.
Outreach campaigns
For population-level interventions, create an outreach campaign (Outreach → New campaign). Target "High risk patients" or filter by specific risk factors. Send messages, schedule appointments, or assign tasks to care managers. Campaign performance is tracked: messages sent, appointments booked, risk score changes.