Population risk stratification: deployment of stratification methods in the Basque Country

The best practices and lessons learnt from the implementation and deployment of a RS in the Basque Country are supposed to serve as examples for the development of programs for managing multi-morbidity among complex frail older citizens, and to help policy makers and stakeholder to design, plan, deploy and validate RS in other regions. A high-quality operational plan establishing the agenda and the strategic goals and objectives for the years to come is needed. Having trained people qualified in RS is necessary. The clinicians’ commitment is a sine qua non requirement. If we can assure the commitment of innovators and early adopters, the remaining organizations will follow in their steps. The communication, not only of RS, but also of what it is aiming for, is a key element of its feasibility. If the clinicians do not see the point of RS, it would be really difficult to implement. Since the clinical group consists of different profiles, it is vital to have a multidisciplinary team leading the RS deployment: each and every one of the professional profiles involved is important. Besides, having appropriate ICT has been identified as crucial. Care intervention includes case finding and selecting the target population allows one to focus efforts on the people that can make the best of the programmes designed for chronic patients. A process of continuous improvement that, on the one hand, includes the quality assessment and improvement process and, on the other hand, the pathway definition and implementation, always helps to produce feasible interventions