The Valley Risk Assessment Tool, created by The Valley Hospital of Ridgewood, NJ, is a two-page, two-column chart that assigns a level to each category of risk.

Here are criteria for patients to qualify for level four:

• One or more chronic diseases with significant risk factors;

• Not at treatment goals;

• Problems with one to three chronic diseases;

• Five or fewer medications from two or fewer prescribing physicians;

• Normal function;

• More or frequent office visits.

A level one simply states that no primary prevention or further intervention is necessary because the “Patient is healthy, with no chronic disease, or significant risk factors; no problems, medications, functional, and utilizations.”

By contrast, a level eight includes:

• Long-term complex: no finances, inadequate social supports;

• Difficult families that need guidance with accessing services and decision-making;

• Housing issues;

• Patients readmitted due to lack of social or financial supports that are complicated;

• Complex, insurance/disability/SSI problems;

• Medication access and affordability issues;

• Cases involving Elder Care Legal Service issues;

• Medicare and Medicaid issues;

• Complex observation patient with discharge needs;

• Multiple resource needs;

• Partial hospitalization programs;

• Outpatient agencies, day programs, psych discharge to community, refusals.