CoCM Risk Scores

Risk Score #1 = Probability of meeting CoCM improvement criteria by Day 90 from baseline.
Risk Score #2 = Probability of meeting CoCM improvement criteria in the next 60 days from the current assessment.
If GAD-7 is left blank, PHQ-only models are used.

Episode Details

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Current Assessments

Date Day since baseline PHQ-9 GAD-7 Item 9 Care Manager Med Started Visit Gap (days)
2025-11-01 0 24 0 0 0 0
2025-12-05 34 21 0 0 0 34
2025-12-12 41 15 0 1 0 7

Risk Scores, Drivers, & Clinical Guidance

Risk Score #1
99.7% chance of CoCM improvement by Day 90
Low risk of non-improvement (green) (PHQ-only model – GAD-7 missing)
Top drivers:
  • Lowest PHQ-9 to date  – 27.1% importance
    decreases probability of improvement
  • Baseline PHQ-9  – 20.3% importance
    increases probability of improvement
  • PHQ-9 at ~30 days (last obs)  – 16.8% importance
    increases probability of improvement
  • Average PHQ-9 to date  – 12.0% importance
    decreases probability of improvement
  • PHQ-9 at ~60 days (last obs)  – 5.1% importance
    increases probability of improvement
Risk Score #2
82.6% chance of CoCM improvement in the next 60 days
Low risk of remaining unimproved in next 60 days (PHQ-only model – GAD-7 missing)
Top drivers:
  • Visit gap variability  – 20.8% importance
    increases probability of improvement
  • Average visit gap (days)  – 20.7% importance
    decreases probability of improvement
  • Highest PHQ-9 to date  – 8.7% importance
    increases probability of improvement
  • Average PHQ-9 to date  – 8.3% importance
    decreases probability of improvement
  • Change in PHQ-9 by 60 days  – 5.3% importance
    increases probability of improvement

Clinical Summary

Risk Score #1 estimates a 99.7% chance of improvement by Day 90 of this episode, which corresponds to a high likelihood of meeting CoCM improvement criteria. Baseline PHQ-9 was 24 (severe), and the most recent score is 15 (moderately severe), indicating a clinically meaningful improvement in depressive symptoms. The patient has previously reached a best (lowest) PHQ-9 of 15, suggesting at least one period of meaningful improvement during this episode. Average time between assessments is about 14 days, consistent with good follow-up frequency. Care manager contact has been moderate; additional proactive outreach could be helpful.

Suggested Actions (Engagement & Care)