Predictive models allow populations to be stratified according to their health requirements for the following year. They offer health care organizations the opportunity to act proactively, designing specific interventions adapted to the level of need of different groups of people. The "Strategy for tackling the challenge of chronic illness in the Basque Country" proposes the use of such models, integrating them with other policies. The prospective categorization of all the population assigned to Osakidetza was performed for the first time in 2010 using the Johns Hopkins Adjusted Clinical Groups predictive model (ACG-PM). For this purpose, already recorded information extracted from electronic health records of primary care and hospital discharge reports was used. This article discusses the advantages of the combined use of various sources of information, and describes the application of the stratification in three programs, targeted at chronic patients who suffer different burdens of comorbidity.

Objective To analyze the results of a 6‐month telephone follow‐up program for the prevention of suicidality in adult patients discharged from three general hospitals after a suicide attempt. Results are compared with traditional programs lasting 12 months or more. Methods This is a prospective, multicenter, study with the control group. Patients in the intervention group received five protocolized telephone calls which were added to their usual treatment. Those in the control group only received usual treatment. Each patient was followed up for 12 months. Results A total of 123 patients were included in the intervention group and 463 in the control group. 57.7% received at least three calls. Patients in the intervention group took longer to perform a reattempt (p = .05). The percentage of those who did a reattempt (p = .67) and the number of reattempts per patient (p = .66) did not differ between groups. Those in the intervention group showed higher percentages of adherence to the outpatient follow‐up (p < .001). Conclusion The intervention was well accepted and showed improved percentages of adherence to outpatient follow‐up; however, the results in the prevention of suicidality were worse than those obtained by programs lasting 12 months or more. It is advisable to maintain the telephone follow‐up for a minimum of 12 months.

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