Table 1.

Care groups in the senior population

Care group	Health status	Risk scores	Clinical indicators	Potential care optimization
1	Robust with no chronic conditions	Low LOH and prospective DxCGa score	Exclusion criteria: chronic conditions, obesity, HIV/AIDS, depression, major mental health issues, substance abuse, skilled nursing facility residence, TIA, dementia or Alzheimer disease, stroke, and most lifelong diseases	Disease prevention, screening, and health promotion services
2	One or more chronic conditions	Moderate LOH and prospective DxCGa score	Exclusion criteria: dementia or Alzheimer disease of > 5 years’ duration, severe organ failure (eg, organ transplant), spinal cord disorders/injuries, severe COPD, stroke, home oxygen therapy, major surgeries or procedures, selected cancers, etc	Disease management
3	Advanced illness and/or end-organ failure	Members not identified by criteria for other groups		Complex case management, advanced illness coordinated care, transitional care, guided care, and geriatric consultation
4	Extreme frailty or near the end of life	High LOH and prospective DxCGa score	Inclusion criteria: end-stage liver disease, liver transplant complications, hepatic coma, metastatic cancer and acute leukemia, abnormal weight loss for those aged > 85 years, current hospice or palliative care, home hospital bed, home oxygen therapy, combinations of dementia or Alzheimer disease and/or frailty, severe dementia documented in physician notes, etc	Home-based care, social work outreach, guided care, palliative care, and hospice care

^aDxCG Intelligence, Verisk Health Inc, Waltham, MA.

COPD = chronic obstructive pulmonary disease; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome; LOH = likelihood of hospitalization; TIA = transient ischemic attack.