This document describes the risk stratification process used by the Camden Coalition of Healthcare Providers to identify high-risk patients for care management interventions. They use hospital utilization data and medical record reviews to determine eligibility and further assess risk factors. Patients are assigned to care teams based on primary care provider. A risk stratification tool is used to measure risk levels and target interventions. Risk scores are re-assessed over time to measure impact and make adjustments to care plans. The goal is to engage the highest risk patients to reduce hospital admissions and lower healthcare costs through improved outcomes.