Skip to main content

Risk from Delayed or Missed Care

View the Toolkit
*Free registration is required to use the toolkits provided within HIPxChange. This information is required by our funders and is used to determine the impact of the materials posted on the website.


During the COVID-19 pandemic, patients may be avoiding medical attention for their conditions for fear of catching the virus or because they are sheltering at home. Health systems have also rapidly transformed care delivery by delaying elective care and shifting to telehealth. There is concern that some patients, particularly those with multiple chronic conditions, will be at risk if delayed or missed care exacerbates long-term complications from their conditions. This looming crisis will likely be compounded by difficulties that patients have in accessing the resources they need to manage their conditions.

Targeting subgroups of patients is a critical component of identifying and managing high healthcare utilizers. This process usually involves targeting high-need high-cost individuals using their personal and clinical characteristics. Health systems often identify patients for enrollment into a program using a predictive model or risk score to find patients at high risk of poor outcomes. The Health Innovation Program’s internal risk score identifies patients at risk of hospital admission or death within six months.

The goal of this toolkit is to enhance the use of a risk score by incorporating indicators from the electronic health record to identify primary care patients at risk if care is delayed or missed during the COVID-19 pandemic. The tool specifically creates a single indicator (yes/no) if the patient has four or more of the indicators. It is intended to be combined with a risk score to identify patients who are both at high risk of poor outcomes and have indicators suggesting they are at risk from missed or delayed care.

Key Reference

Smith M, Vaughan Sarrazin M, Wang X, Nordby P, Yu M, DeLonay AJ, Jaffery J. Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic. J Am Geriatr Soc. [Epub ahead of print]

Who should use this toolkit?

This risk stratification toolkit is intended to support health system administrators and researchers interested in reaching out to patients at risk if care is delayed or missed due to the COVID-19 pandemic.

What does this toolkit contain?

The indicators identified in this toolkit are meant to identify patients at risk for long-term complications from their conditions, or patients that may have difficulty in accessing the resources they need to manage their conditions if care is delayed or missed due to the COVID-19 pandemic. These indicators capture different subgroups of patients who are at risk: patients with chronic physical conditions, patients with mental health conditions, frail patients, patients with disabilities, and patients who may be affected by social determinants of health. These particular subgroups of patients are often the targets for improved targeting and care by health systems.

Patients with one of or a combination of comorbidities, disability, and/or frailty have been identified with increased healthcare needs and costs (Fried 2004) and are at risk for complications if their conditions are not managed. However, during the pandemic, emergency room visits have also decreased, putting patients at risk from complications of acute events such as heart attack or stroke that could be prevented (Masroor 2020). The CDC (2020) has recommendations for multiple subgroups of patients who need extra attention during the COVID-19 pandemic, including patients with disabilities, patients with developmental and behavioral disorders, those experiencing homelessness, and patients with drug use and substance use disorder. They recommend that patients with developmental and behavioral disorders continue with their regular care routine, but they may have difficulty accessing information or practicing preventative measures on their own. Similarly, patients who are homeless are often older and have underlying medical conditions and are at increased risk.

The toolkit contains definitions for identifying the following indicators for delayed or missed care:

  • Chronic physical conditions
    • Five or more unique medications ordered or billed in last year
    • Any diagnosis of cardiovascular disease or stroke
    • Uncontrolled hypertension: most recent systolic BP >140 or diastolic BP >90 and either a diagnosis of hypertension or on the hypertension registry
    • Uncontrolled diabetes: most recent A1c >=9 and either a diagnosis of diabetes or on the diabetes registry 
    • End-stage liver disease
    • End-stage renal disease or stage IV/V chronic kidney disease
  • Chronic mental conditions
    • Bipolar, schizophrenia, psychotic disorders (diagnosis codes or on problem list)
    • Behavior and personality disorders on problem list
    • Substance abuse on problem list
    • Mental health related hospitalization or ED visit in last year 
  • Frailty
    • Three or more Johns Hopkins frailty indicators (e.g. incontinence, mobility, cognitive impairment, falls, malnutrition)
  • Disability
    • Any hearing-impairment-related condition
  • Social determinants of health
    • Two or more no-show appointments in last year
    • Indicators of homelessness or poverty
  • Utilization
    • Unplanned hospitalization in last year
    • Emergency department visit in last year

How should these tools be used?

When used in combination with a health system’s risk score, this tool will identify adults who are at risk if care is missed or delayed.

A copy of the definitions for these indicators and information on adapting them is available in this PDF file.

Development of this toolkit

The Risk from Delayed or Missed Care toolkit was built by staff at the Health Innovation Program at the University of Wisconsin – Madison School of Medicine & Public Health. The mission of the Health Innovation Program is to transform healthcare delivery and population health across the state and nation through health systems research that partners University of Wisconsin faculty with healthcare and community organizations.

This project was supported by grant PCORI Grant # HSD-1603-35039. Additional support was provided by the University of Wisconsin School of Medicine and Public Health’s Health Innovation Program (HIP), the Wisconsin Partnership Program, and the Community-Academic Partnerships core of the University of Wisconsin Institute for Clinical and Translational Research (UW ICTR), grant 9 U54 TR000021 from the National Center for Advancing Translational Sciences (previously grant 1 UL1 RR025011 from the National Center for Research Resources). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funders.

Please send questions, comments and suggestions to


  1. Smith M, Vaughan Sarrazin M, Wang X, Nordby P, Yu M, DeLonay AJ, Jaffery J. Risk from delayed or missed care and non-COVID-19 outcomes for older patients with chronic conditions during the pandemic. J Am Geriatr Soc. [Epub ahead of print]
  2. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004 Mar;59(3):255-63.
  3. Masroor S. Collateral damage of COVID-19 pandemic: delayed medical care. J Card Surg. 2020 Jun;35(6):1345-1347.
  4. Centers for Disease Control and Prevention. 2020.

Toolkit citation

Health Innovation Program. Risk from Delayed or Missed Care. Health Innovation Program. Madison, WI; 2020. Available at

UWSMPH Logo                  HIP logo

  • The target group

Related Tools