Population Health Stratification & Risk Scoring

Empower your care team with data-driven insights to proactively manage patient populations. Our Population Health Stratification & Risk Scoring service identifies at-risk individuals, enabling early intervention, resource prioritization, and improved health outcomes. By leveraging predictive analytics and real-time data, healthcare providers can reduce costs, prevent complications, and deliver more targeted, effective care.

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Population Health Stratification & Risk Scoring

At MRG Health, our Population Health Stratification & Risk Scoring service empowers healthcare organizations to make informed, proactive decisions. Using advanced digital health assessments, data analytics, and clinically validated algorithms, we identify high-risk patients based on specialty-specific conditions, chronic diseases, and social determinants of health (SDOH).

 

Risk Factors
  • Body Mass Index
  • Behavioral Health Index
  • Biometric Vital Thresholds
  • PHQ - 9
  • Activities of Daily Living
  • Fall Risk
  • Health Literacy
  • Safe Living Situation
  • Housing Status
  • Transportation
  • Financial Issues
  • Literacy Level Evaluations
  • Preventative Screenings

MRG Health’s rapid screening capabilities allow providers to collect essential health data in just minutes—enabling a proactive, preventative approach to patient care. By identifying risk factors early, care teams can improve clinical outcomes, increase patient compliance, and connect individuals with the social services they need. This approach helps close care gaps and supports a more effective population health management strategy.

Team-Based Care Approach

We cover the full spectrum of qualified healthcare professionals to meet your patient population’s needs ALL in one platform.

Identify High Risk Patients Sooner

Using advanced algorithms and digital assessments, our platform helps healthcare teams pinpoint at-risk individuals earlier enabling timely, preventative care.

Generate Personalized Health Risk Scores

Each patient receives a tailored health index score based on clinical data, biometric inputs, behavioral health, and social determinants of health, supporting better decision making.

Streamline Screening With Built In Tools

Quickly assess patients using standardized tools such as BMI, PHQ-9, ADLs, and fall risk all integrated into a single platform to simplify workflows.

Improve Care Coordination Across Teams

Stratified population data makes it easier to prioritize care, close care gaps, and ensure patients receive the right services at the right time.

Align With Population Health Goals

Our solution supports healthcare organizations in delivering targeted, preventive care strategies that align with population health and quality improvement initiatives.

Drive Better Clinical and Operational Outcomes

Transform raw patient data into actionable insights to guide resource allocation, reduce complications, and enhance the quality of care.

Benefits

For Practices

  • Streamline patient risk assessments with automated tools
  • Identify high risk patients early for timely care interventions
  • Improve operational efficiency through data driven stratification
  • Allocate clinical resources more effectively across patient populations
  • Support value based care initiatives and performance goals
  • Close gaps in care with real-time health risk insights
For Patients
  • Receive earlier identification of potential health risks
  • Gain access to more personalized and preventive care
  • Experience fewer complications through timely interventions
  • Stay more engaged in managing their own health
  • Get connected with the right care and support services faster
  • Benefit from care plans tailored to individual health needs

Personalized Health Index Scoring

Each patient receives a unique health score based on biometric, behavioral, and lifestyle assessments. These scores help guide care plans that are tailored to individual risk profiles and health needs...

Proactive Risk Identification

MRG Health’s platform helps providers detect at-risk patients early by analyzing clinical data, behavioral trends, and social determinants of health. This proactive approach reduces complications and improves long-term outcomes.

Support for Care Gap Closure

By identifying missed preventive services or unmanaged conditions, our system supports care teams in closing gaps efficiently, ensuring patients stay on track with recommended treatments and screenings..

Actionable Population Health Insights

Aggregate patient data is turned into meaningful insights that guide practice-wide decision-making, support public health strategies, and align with value-based care initiatives.

Seamless Integration into Clinical Workflows

MRG Health’s platform fits naturally into existing workflows, helping care teams save time while enhancing accuracy, documentation, and care coordination without disrupting daily operations..

Real-Time Data Collection & Analysis

Our platform captures and analyzes patient data in real time, allowing care teams to make faster, more informed decisions. This leads to timely interventions and more effective population health strategies...

Interested in learning more about what patients are eligible to participate and how risk stratification tools will assist the clinic staff and patients?

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(FAQs) – Population Health Stratification & Risk Scoring

Population Health Stratification and Risk Scoring is a data-driven approach used to categorize patient populations based on risk factors, health conditions, and social determinants. At MRG Health, this process helps identify high-risk individuals for early intervention and personalized care.

MRG Health leverages advanced digital assessments and algorithms to assign health risk scores. These scores help providers prioritize care, close gaps, and allocate resources where they’re most needed—improving outcomes across patient populations.

We use a combination of clinical data, behavioral health assessments, biometric thresholds, and social determinants of health to accurately evaluate risk and predict potential health outcomes.

Both patients and healthcare practices benefit. Patients receive more targeted and proactive care, while practices gain valuable insights for better decision-making, resource management, and quality improvement.

Yes. By identifying at-risk patients early, MRG Health’s risk scoring system enables preventive strategies that reduce the likelihood of chronic disease progression or emergency care needs.

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LUCAS KRAUSE
PhD MSC
 IT Infrastructure & Architecture 
Lucas is a 20+ year experience enterprise Cloud Solutions Architect who has worked with fortune 100 companies and is competent in the following: Enterprise API Gateways – AWS | Azure | Salesforce | Mulesoft | Apigee | IBM Cloud | Anypoint | Cloud Data Warehouse – Snowflake | DBT | Cloudara | Airflow | Kubernetes | AWS | Looker | Prometheus | Full-Stack / Cloud Native – C# / Java / React / Angular / Golang / Python – Cloud DBs – Dynamo / Mysql / Postgres / MSSql / Oracle / Netezza
RENE HINOJOSA
MBA
Compliance & Regulatory 
Experienced Director of Strategic Development with a demonstrated history of spearheading initiatives throughout the healthcare system. Skilled in Physician Relations, Software Documentation, Healthcare Management, Healthcare, and Public Speaking. Strong program and project management professional with years of a proven track record that showcases a creative and proficient skill-set in problem solving.
TY UMOH
MD MBA
Investor Relations & Finance 
Ty has a bachelor’s degree in Accounting & Finance from the University of Houston and a Master’s degree in Economics and Corporate Finance from Rice University. Previously, Ty worked as a senior consultant at FTI Consulting, Inc., advising various stakeholders of troubled and distressed companies across a wide range of industries, including financial services, hospitality, gaming, commercial real estate, energy & oil field services, construction, infrastructure, and municipal-related assets. Additionally, my prior experience includes roles at BNY Mellon and Ocean Park Advisors, LLC’s Investment Bank where I was involved in equity and debt capital raising transactions as well as M&A assignments, liquidity forecasting and assessments, business plan due diligence, development of waterfall and recovery analyses, stakeholder negotiations, plan of reorganization development, M&A/transaction advisory including purchase and sale negotiations and seller due diligence support, board/shareholder representation, developing executive compensation/bonus plans, and ad-hoc strategic and operational assessments.
JAVI MALCOLM
MD 
Strategic Development
Dr Malcom’s Medical Professional qualities are based on 10+ yrs. of participation and exposure to numerous resources as an ER Medical Business Co-Founder, IT Market Leader, Mentor, Red Cross Humanitarian Participant, Graduate of Masters Studies, Graduate of Medical Doctorate (M.D.), Hospital Administrator, and member of the Physician Executive Team. My unique background and combination of these attributes & skills have created a unique innovative space that helps reinforce my ability to grasp the different areas of healthcare that positively impact the hospital ecosystem and be a valuable member of the C-Suite team, as DHR Health’s Chief Medical Information Officer, Physician Executive Leadership Committee, and the Cerner Advisory Committee.
Dr. Jill Taylor
DO Pharmacologist
Chief Clinical Officer​

It is important to learn about the doctor with whom you trust your health. A combination of formal education, training, and experience form Dr. Taylor’s credentials, which uniquely qualify her to provide you with the best approach to achieving your optimum health

Here are a few highlights:

  • Specializing in Family Practice. Fully licensed in Texas
  • Graduated New York Institute of Technology, New York College of Osteopathic Medicine 1989
  • Worked in Medical, Drug, and Disease Research for three years as a Pharmacologist
  • Worked in academic medical research for three years
  • Holds patents in Disease Research
  • Has publications in several Medical Journals
  • Speaks Medical Spanish
NARIO CANTU
Pharmacist
Senior Executive Director
Dispensing, assessing and monitoring medications, in patients requiring pharmaceutical therapy. Providing and assessing point of care testing. Providing excellent service and customer satisfaction. Drug information and education. hospital readmission prevention consultant, transition care provider, medication reconciliation provider, pharmacogenomic testing, point of care testing. Medication Therapy Management, medication adherence and legislative advocate as it pertains to pharmacy and patient care.
SABRINA RUNBECK
MPH, MHS, PA-C
Director People & Clinical Outcomes 

Physician Assistant turned Entrepreneur with Bachelor in Neuroscience, Masters in Public Health and Health Sciences, After working 80 hours a week as a cardiothoracic surgery physician associate, my workload took a toll on my personal and professional life. That was when I realized my life needed to change. I ended up taking a deep dive into performance sciences and positive intelligence. As a result, I cut down my clinical hours by 30% and increased my income by 50%.

Reggie Abraham
PhD, MHA, MBA
Managing Director  
UTHealth-MRG Health

Experienced Healthcare Executive with a demonstrated history of working in a hospital setting and various other health care facilities. Skilled in Healthcare Operations, EHR & PM Systems, Budgeting, HR Management, Strategic Planning, and Revenue Cycle Management, . Strong business development professional with a Doctorate in Management and Organizational Leadership, Master’s in Healthcare Administration, Master’s in Business Administration. Exceptional track record of establishing strong leadership teams and developing effective operational efficiencies in healthcare operations. Establish and maintain good working relationships with physicians, staff, vendors, government agencies, managed care companies, and clients.

KYLE CHRISTOPHER
Vascular General, Cardiac, OB Sonography
Founder/CEO - Strategic Development  
Assists Physicians and Healthcare Executives in Leveraging Virtual Care Management Technologies, NEW Billable CPT Codes, and Value Based Care Models to Improve Clinical Outcomes and Create NEW Revenue streams. Kyle holds a Bachelors of Science in Business Administration with a minor in marketing, and a Degree in Vascular, General, Cardiac, and Obstetrical Sonography. His philanthropy work focuses on veteran affairs, single mothers, first responders, and mentoring terminally ill and at-risk youth through organizations such as Beauty for Freedom, Ferrari Kid, Southwest Keys Program, ICON Talks, and Living Beyond A Dream.