IPCHS. Integrated People-Centred Health Services


Aug. 30, 2016 Leading practice Europe

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.

Description of practice
City: Venice Country: Italy
The problem

Despite Veneto reporting health outcomes above the national average, regional government officials grew concerned by the emerging epidemic of multimorbidity in Veneto’s ageing population, as well as the growing inability of the current health system to efficiently care for chronic patients. Emerging health pressures necessitated more continuous and proactive care for patients, but delivery of this type of care proved problematic given the reactive orientation of the system. Rising care costs were a further concern and the current system was no longer considered to be financially sustainable.

The solution

After looking to international health systems for potential solutions, an ambitious three-year pilot project was launched in Veneto to introduce Adjusted Clinical Groups (an integrated data management tool developed by Johns Hopkins University in the United States of America) as a means to identify patients at high risk for chronic disease for proactive outreach and preventive care, reducing the need for more costly services at later stages. Adjusted Clinical Groups measure the morbidity burden of patient populations based on disease patterns, age and gender. They rely on information found in insurance claims, prescriptions or other electronic medical records to build a comprehensive picture of morbidity within populations, subgroups and individuals. As a key part of the pilot, general practitioners receive lists of high-risk patients in their geographic area developed by statisticians at the local level. General practitioners are then responsible for proactively reaching out to prioritized patients, recruiting them into care and closely monitoring their health. Nursing roles have been advanced to support new processes called for by the initiative, positioning nurses to work in partnership with general practitioners and awarding them additional care responsibilities. Patients are also increasingly involved in the management of their own care. Implementation of Veneto’s pilot project has occurred gradually in three phases: phase one (2012–2013) was an exploratory period to test the feasibility of the project within two of Veneto’s 21 local health and social care units; phase two (2013–2014) expanded the project to six local units and involved health providers in planning ways to improve care for high-risk patients and; phase three (2014–2015) scaled up the project across the entire region.

Implementation of practice
What stage is the practice currently in?

Pilot stage

Who was/is responsible for the implementation of the practice?

Pioneers of utilizing Adjusted Clinical Groups in Italy, regional government officials in Veneto showed significant foresight in their willingness to explore new solutions to emerging health issues. International actors, notably Johns Hopkins University (where the Adjusted Clinical Groups concept was developed) and the example of Sweden (where the approach was seen being applied), were instrumental in providing inspiration and structural guidance for the initiative. Local actors in Veneto were, however, also heavily engaged throughout the initiative to ensure buy-in for proposed changes and support adaptations to the local context. The Regional Government of Veneto assembled a working group composed of local experts to lead the initiative and champions were recruited among providers to stimulate the involvement of the health workforce.  


Outcomes will be assessed by a final evaluation of the pilot in 2016, the results of which will determine whether the initiative continues to be implemented and secured with formal policy. However, key informants report observing indirect indicators of success and the initiative has already generated considerable interest from other Italian regions.    

Additional information

This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".

© Copyright World Health Organization (WHO), 2016

The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.


Please click on the link below for more information about this practice. 

Contact information
Maria Chiara Corti
Giunta Regionale, Area Sanità e Sociale
Add your comment

Sign in to add your comment.