✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 22, 2025.
Healthcare analytics tools use data and statistics to identify at-risk individuals who may benefit from case management services. The tools include health risk assessments, predictive modeling, and adjusted clinical groups. The goal is to proactively provide case management services to prevent disease, complications, morbidity, mortality, and hospitalization, and by doing so, reduce costs and improve patients’ quality of life.
Health risk assessment (HRA)
A health risk assessment (HRA) is a tool for assessing a patient’s health status, risk of adverse health outcomes, and readiness to change certain behaviors. Based on a patient’s HRA results, a prevention plan may be developed, so the patient can take action to improve his health status and delay or prevent disease caused by reported at-risk behaviors.
An HRA has three components: questionnaire, risk calculation, and feedback. To calculate a patient’s risk, a healthcare provider or software application (often using machine learning or artificial intelligence) reviews the questionnaire responses and biometric data, assesses the patient’s health status, and evaluates the risk of developing certain diseases, disabilities, or injuries.
The third component of an HRA is personalized feedback from a healthcare provider, which aims to reduce risk factors by suggesting appropriate interventions and providing motivation to change unhealthy or high-risk behaviors.
Medicaid uses HRAs during enrollment to identify individuals with health problems that need immediate attention. The Affordable Care Act requires that an HRA be included in the annual wellness visit for Medicare beneficiaries, and that it must identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs. HRAs, also called health assessments or wellness profiles, are also used by employers for wellness programs and by health insurance companies to identify individuals for disease management programs.
Predictive modeling
Predictive modeling uses technology to statistically analyze enormous amounts of data (often retrieved from health plan claims) to predict outcomes for individual patients. The data examines physician, specialist, laboratory, pharmaceutical, ER, and hospital usage patterns.
Adjusted clinical group (ACG)
The adjusted clinical group (ACG) system is a tool developed by Johns Hopkins University to assess risk. It uses the diagnostic and pharmaceutical code information from insurance claims and electronic medical records to measure morbidity in large populations based on disease patterns, age, and gender. It provides an accurate representation of the morbidity burden of populations, subgroups, or individual patients based on the overall picture, not on individual diseases. This information is used to evaluate provider performance more accurately and fairly, set equitable payment rates, forecast healthcare utilization, and identify patients at high risk.
This article shares a portion of the information covered on healthcare analytics in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details on this topic and related concepts, purchase your copy at CCMCertificationMadeEasy.com
