Identifying high-risk chronic patients for targeted primary care intervention in Veneto, Italy
Adjusted Clinical Groups were introduced in primary care as a means to proactively target patients at high risk for chronic disease with personalized health interventions and preventive services; when designing the initiative, leaders sought out existing solutions from abroad which could be adapted for application in Veneto; gradual implementation of the initiative through a three-phase pilot project allowed time to explore, verify and refine activities before scaling up across Veneto; services were reoriented to become more proactive, nurses were awarded additional responsibilities related to patient outreach and patients’ own role in their care was increased; Veneto's existing strong data collection system was essential for allowing predictive risk modelling using Adjusted Clinical Groups. The initiative capitalized on the “goldmine” of data already being collected for administrative purposes.