Clinical Stratification Domains


Patient-based assessment of health risk is used to allocate the patients into specific integrated care programs

Purpose: optimizing care and generating efficiencies. 

Allocation into a program will depend on two main factors:

  1. health status and associated risk level; and,
  2. target health goals planned.

Note: specific indicators for patient-based stratification may unavailable in the initial phase of the project, due to unavailability in the regional programs.


Conceptual definitions guiding the population-based stratification and the description of the methodological steps followed to obtain population-based indicators


  • Purpose:  primary objective.  What is the purpose of the stratification? {public health purposes, cost savings, enhance efficiency of services,…}
  • Process: the sources of information and the method used to generate the indicators.  When is the stratification performed? {after diagnosis, after hospitalization,…}
  • Frequency:  Time frame and periodicity of the analysis. What is the frequency of stratification {quarterly / yearly / biyearly …}
  • Combination method: How are the elements of the stratification combined? Is <domain/subdomain> considered in the stratification?


Health status

the individual impact of the disease on the patient’s health status

Patient health status impacts patient health outcomes, engagement for and adherence to the program.


  • Severity: characterizes the state of the disease, based on classifications in international clinical guidelines. HF: NYHA, COPD: GOLD.
  • Activity: captures disease progression. Measured by frequency & intensity of exacerbations
  • Co-morbidities: comorbidities are associated with worse health outcomes and disease burden. The Charlson index.
  • Care resource use: frequency of use of healthcare services. Which time frame is used? {30/60/90 days, 1 year}? Which measure is used? {…}



Characterizes the patient risk for an adverse event

Patients who are impaired, have less social support or have more complex care are more likely to have difficulties in following a program.


  • Function: the physical impairment of the patient in daily life. Which scales are used? {dressing, eating, ambulating, toileting, hygiene}
  • Fall risk: Which measure is used? {…}
  • Social support: the availability of informal care givers or established social support. Which scales are used? {…}
  • Care complexity: the care needs of patients who have multi-morbid conditions. Which measure is used? {…}



Encompasses several indices reflecting external factors that have proven influence on health status and accessibility and use of healthcare services.


  • Attitude: the way the patient deals with his condition. Which measure is used? {…}
  • Skills: the ability of the patient to use the CCTH service. Which measure is used? {…}
  • Deprivation: the level of poverty in the area where the patient lives. Deprivation index.
  • Education: the education level op the patient.
  • Age: the age of the patient.