The QI project utilized the Plan-Do-Study-Act (PDSA) cycle methodology to guide the project. A multidisciplinary team selected and integrated the Risk of Hospital Admission or ED Visit Stratification (RHA/EDVS) risk stratification tool into the clinic’s electronic health record (EHR), trained staff on population health and risk stratification, and implemented workflows to mitigate risk. Pre- and post-implementation surveys measured staff knowledge gains. Process measures included trainings delivered, workflows developed, and high-risk rosters created.