chronic-condition-cohorting

Segment patient populations into chronic disease cohorts using CMS CCW algorithms.

1|1|Updated Feb 19, 2026

Search Tags:#healthcare #risk stratification #population health #patient cohorting #care management #chronic conditions

Ready to run

npx skills add https://github.com/GoldenZero/skills --skill chronic-condition-cohorting-goldenzero

💬 Prompt for ChatGPT / Claude Chat▼

Please help me install this Agent Skill.
Skill: chronic-condition-cohorting
Source: https://github.com/GoldenZero/skills/tree/main/skills/chronic-condition-cohorting
Command: npx skills add https://github.com/GoldenZero/skills --skill chronic-condition-cohorting-goldenzero

SYSTEM DOCUMENTATION & REQUIREMENTS

💡 This Skill includes scripts (resource) and references (resource) and assets (resource) components.

What problem does it solve?

This Skill automates the complex process of identifying, segmenting, and analyzing patient populations based on chronic conditions, enabling targeted care management and risk stratification.

Core Features & Use Cases

Disease Cohorting: Creates specific patient groups for conditions like diabetes, COPD, CHF, and CKD.
Severity Stratification: Segments patients within cohorts based on clinical severity and risk.
Multi-Morbidity Analysis: Identifies patients with multiple chronic conditions and complex needs.
Use Case: A health system can use this skill to identify all diabetic patients with an HbA1c above 9% and a recent ER visit to proactively enroll them in a specialized diabetes management program.

Quick Start

Use the chronic-condition-cohorting skill to build a cohort of all diabetic patients in the provided claims data.

Frequently Asked Questions about chronic-condition-cohorting

High-intent search queries and answers about installing and using this skill.

FAQPage Schema

How do I segment patients by chronic condition risk using claims data?▼

You can segment patients by chronic condition risk by applying CMS Chronic Conditions Warehouse algorithms and HCC groupings to structured claims, enrollment, pharmacy, and optional lab data to produce clinically meaningful cohorts.

What data do I need for chronic disease cohorting and severity stratification?▼

Chronic disease cohorting and severity stratification require structured claims, enrollment, and pharmacy data, while optional lab and demographic data enhance clinical severity staging and multi-morbidity analysis accuracy.

Can I identify diabetic patients with high HbA1c and recent ER visits for care management?▼

Yes, you can identify diabetic patients with an HbA1c above 9% and recent ER visits by combining pharmacy claims, lab values, and utilization patterns to proactively target them for specialized diabetes management programs.

What is the best way to stratify patient populations for multi-morbidity analysis?▼

The best way to stratify patient populations for multi-morbidity analysis is applying clinical severity staging and HCC groupings to identify patients with multiple chronic conditions and complex care management needs.

Does patient cohorting work with CMS Chronic Conditions Warehouse and HCC groupings?▼

Yes, patient cohorting works directly with CMS Chronic Conditions Warehouse algorithms and HCC groupings to risk stratify populations and generate actionable segments for quality reporting and care management.

When should I not use claims-based chronic condition cohorting for risk stratification?▼

You should not use claims-based chronic condition cohorting when you lack structured claims, enrollment, or pharmacy data, as these inputs are required to apply CCW algorithms and produce reliable patient segments.