Identifying a high-risk cohort does not by itself change outcomes. Most programmes stall in the step between a list and an action.
The effective pattern is to embed the risk tier directly into existing workflow: who sees the information, at what moment, what decision they are expected to make, and where it is recorded.
It also helps to state explicitly when not to intervene. Letting a care team reasonably disregard a low-priority alert is what keeps the signal trustworthy over time.