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CCPP Certification Program
Module 11: Patient Identification and Risk Stratification
Shifting from a Reactive to a Proactive Stance in Patient Care.
From Reactive Dispensing to Proactive Intervention
Throughout your career in pharmacy, your expertise has been primarily deployed in a reactive manner. A patient presents with a prescription—a defined problem with a proposed solution—and you apply your skills to ensure its safety, appropriateness, and proper fulfillment. You are a master of managing the needs that walk through your door.
This module marks a fundamental shift in that paradigm. As a collaborative practice pharmacist, your greatest value lies not in waiting for problems to arrive, but in proactively identifying the patients who are most likely to develop problems in the future. You are moving from managing prescriptions to managing populations. Your focus expands from the individual patient in front of you to the entire panel of patients under your care, and your primary task is to find the needles in the haystack—the high-risk individuals who will benefit most from your intervention before an adverse event or hospitalization occurs.
This requires a new skillset grounded in data analysis, risk stratification, and population health principles. You will learn to use the tools within the EHR and other data systems not just as a record-keeping device, but as a powerful diagnostic instrument for assessing the health of a patient panel. By mastering the ability to identify and stratify at-risk patients, you transform your role from a trusted dispenser of medications into an essential architect of preventative care and a true population health manager.
Your Module Roadmap
This module will equip you with the systematic approach needed to find, enroll, and manage the patients who need you most.
Selecting Target Populations for Collaborative Care
Learn to identify high-impact disease states and patient groups where pharmacist-led interventions deliver the highest clinical and financial return on investment.
Using Risk Stratification Tools and Data Analytics
A deep dive into using EHR-based registries, predictive analytics, and risk scoring models to pinpoint high-risk patients within a larger population.
Enrollment, Consent, and Care Coordination Processes
Master the practical workflows for enrolling patients into your service, obtaining proper consent, and establishing clear communication channels with the rest of the care team.
Addressing Social Determinants of Health
Learn to identify and integrate non-clinical factors like transportation, housing, and food security into your risk assessment to provide truly holistic care.
Prioritization and Follow-Up Strategies
Develop effective strategies for managing a panel of high-risk patients, including how to prioritize outreach and establish appropriate follow-up intervals.
