How to handle multiple hierarchies in a data model? In Sql Server, there is a datatype called HIERARCHYID which helps with hierarchies. In our environment, we have patient data that needs to be classified under multiple hierarchies.

Example 1: Hierarchy1, that categories patient's based on geography.     

Country >> state >> etc... .  


A Patient can only be identified in one node of the hierarchy.  
When a patient moves, their association with node is also moved to appropriate new node. 


Example 1: Hierarchy2, based on benefits they claim, they are put into one program or another. 

Program >> CCMA >> etc

Again, same rules as before apply:  


A Patient can only be identified in one node of the hierarchy.  
When a patient changes plans (program), their association with node is also moved to appropriate new node. 


We could have 1 or 2 or ... n hierarchies. How do we handle them?

This is different from Patient_Groups that are used for ad hoc grouping.

Thanks,
Jeff Moden has written two excellent articles on SQL Hierarchies here (Hierarchies on Steroids #1) and here (Hierarchies on Steroids #2) which present efficient SQL algorithms for converting hierarchies stored as an Adjacency List (ie children have a Parent pointer - easier to visualize and more efficient to create) to a temporary table organized as nested sets (more efficient for reporting).

Given Jeff's good work in describing how to efficiently convert to Nested Sets as needed, I would recommend storing and maintaining your hierarchies as a Adjacency Lists. 

By making each Hierarchy an independent table you will gain the benefit of decoupling the hierarchies from the base patient data, facilitating the addition of additional hierarchies as required.

The Code (Thank you Jeff):

 CREATE PROCEDURE dbo.RebuildNestedSets AS
/****************************************************************************
 Purpose:
 Rebuilds a "Hierarchy" table that contains the original Adjacency List,
 the Nested Sets version of the same hierarchy, and several other useful 
 columns of data some of which need not be included in the final table.

 Usage:
 EXEC dbo.RebuildNestedSets

 Progammer's Notes:
 1. As currently written, the code reads from a table called dbo.Employee.
 2. The Employee table must contain well indexed EmployeeID (child) and
    ManagerID (parent) columns.
 3. The Employee table must be a "well formed" Adjacency List. That is, the
    EmployeeID column must be unique and there must be a foreign key on the
    ManagerID column that points to the EmployeeID column. The table must not
    contain any "cycles" (an EmployeeID in its own upline). The Root Node
    must have a NULL for ManagerID.
 4. The final table, named dbo.Hierarchy, will be created in the same 
    database as where this stored procedure is present.  IT DOES DROP THE 
    TABLE CALLED DBO.HIERARCHY SO BE CAREFUL THAT IT DOESN'T DROP A TABLE 
    NEAR AND DEAR TO YOUR HEART.
 5. This code currently has no ROLLBACK capabilities so make sure that you
    have met all of the requirements (and, perhaps, more) cited in #3 above.

 Dependencies:
 1. This stored procedure requires that the following special purpose HTally
    table be present in the same database from which it runs.

--===== Create the HTally table to be used for splitting SortPath
 SELECT TOP 1000 --(4 * 1000 = VARBINARY(4000) in length)
        N = ISNULL(CAST(
                (ROW_NUMBER() OVER (ORDER BY (SELECT NULL))-1)*4+1
            AS INT),0)
   INTO dbo.HTally
   FROM master.sys.all_columns ac1
  CROSS JOIN master.sys.all_columns ac2
;
--===== Add the quintessential PK for performance.
  ALTER TABLE dbo.HTally
    ADD CONSTRAINT PK_HTally 
        PRIMARY KEY CLUSTERED (N) WITH FILLFACTOR = 100
;

 Revision History:
 Rev 00 - Circa 2009  - Jeff Moden 
        - Initial concept and creation.
 Rev 01 - PASS 2010   - Jeff Moden 
        - Rewritten for presentation at PASS 2010.
 Rev 02 - 06 Oct 2012 - Jeff Moden
        - Code redacted to include a more efficient, higher performmance
          method of splitting the SortPath using a custom HTally Table.
****************************************************************************/
--===========================================================================
--      Presets
--===========================================================================
--===== Suppress the auto-display of rowcounts to prevent from returning
     -- false errors if called from a GUI or other application.
    SET NOCOUNT ON;

--===== Start a duration timer
DECLARE @StartTime DATETIME,
        @Duration  CHAR(12);
 SELECT @StartTime = GETDATE();

--===========================================================================
--      1.  Read ALL the nodes in a given level as indicated by the parent/
--          child relationship in the Adjacency List.
--      2.  As we read the nodes in a given level, mark each node with the 
--          current level number.
--      3.  As we read the nodes in a given level, convert the EmployeeID to
--          a Binary(4) and concatenate it with the parents in the previous
--          level's binary string of EmployeeID's.  This will build the 
--          SortPath.
--      4.  Number the rows according to the Sort Path.  This will number the
--          rows in the same order that the push-stack method would number 
--          them.
--===========================================================================
--===== Conditionally drop the final table to make reruns easier in SSMS.
     IF OBJECT_ID('FK_Hierarchy_Hierarchy') IS NOT NULL
        ALTER TABLE dbo.Hierarchy
         DROP CONSTRAINT FK_Hierarchy_Hierarchy;

     IF OBJECT_ID('dbo.Hierarchy','U') IS NOT NULL
         DROP TABLE dbo.Hierarchy;

RAISERROR('Building the initial table and SortPath...',0,1) WITH NOWAIT;
--===== Build the new table on-the-fly including some place holders
   WITH cteBuildPath AS 
( --=== This is the "anchor" part of the recursive CTE.
     -- The only thing it does is load the Root Node.
 SELECT anchor.EmployeeID, 
        anchor.ManagerID, 
        HLevel   = 1,
        SortPath =  CAST(
                        CAST(anchor.EmployeeID AS BINARY(4)) 
                    AS VARBINARY(4000)) --Up to 1000 levels deep.
   FROM dbo.Employee AS anchor
  WHERE ManagerID IS NULL --Only the Root Node has a NULL ManagerID
  UNION ALL 
 --==== This is the "recursive" part of the CTE that adds 1 for each level
     -- and concatenates each level of EmployeeID's to the SortPath column.  
 SELECT recur.EmployeeID, 
        recur.ManagerID, 
        HLevel   =  cte.HLevel + 1,
        SortPath =  CAST( --This does the concatenation to build SortPath
                        cte.SortPath + CAST(Recur.EmployeeID AS BINARY(4))
                    AS VARBINARY(4000))
   FROM dbo.Employee      AS recur WITH (TABLOCK)
  INNER JOIN cteBuildPath AS cte 
          ON cte.EmployeeID = recur.ManagerID
) --=== This final INSERT/SELECT creates the Node # in the same order as a
     -- push-stack would. It also creates the final table with some
     -- "reserved" columns on the fly. We'll leave the SortPath column in
     -- place because we're still going to need it later.
     -- The ISNULLs make NOT NULL columns
 SELECT EmployeeID = ISNULL(sorted.EmployeeID,0),
        sorted.ManagerID,
        HLevel     = ISNULL(sorted.HLevel,0),
        LeftBower  = ISNULL(CAST(0 AS INT),0), --Place holder
        RightBower = ISNULL(CAST(0 AS INT),0), --Place holder
        NodeNumber = ROW_NUMBER() OVER (ORDER BY sorted.SortPath),
        NodeCount  = ISNULL(CAST(0 AS INT),0), --Place holder
        SortPath   = ISNULL(sorted.SortPath,sorted.SortPath)
   INTO dbo.Hierarchy
   FROM cteBuildPath AS sorted
 OPTION (MAXRECURSION 100) --Change this IF necessary
;
RAISERROR('There are %u rows in dbo.Hierarchy',0,1,@@ROWCOUNT) WITH NOWAIT;

--===== Display the cumulative duration
 SELECT @Duration = CONVERT(CHAR(12),GETDATE()-@StartTime,114);
RAISERROR('Cumulative Duration = %s',0,1,@Duration) WITH NOWAIT;

--===========================================================================
--      Using the information created in the table above, create the
--      NodeCount column and the LeftBower and RightBower columns to create
--      the Nested Sets hierarchical structure.
--===========================================================================
RAISERROR('Building the Nested Sets...',0,1) WITH NOWAIT;

--===== Declare a working variable to hold the result of the calculation
     -- of the LeftBower so that it may be easily used to create the
     -- RightBower in a single scan of the final table.
DECLARE @LeftBower INT
;
--===== Create the Nested Sets from the information available in the table
     -- and in the following CTE. This uses the proprietary form of UPDATE
     -- available in SQL Serrver for extra performance.
   WITH cteCountDownlines AS
( --=== Count each occurance of EmployeeID in the sort path
 SELECT EmployeeID = CAST(SUBSTRING(h.SortPath,t.N,4) AS INT), 
        NodeCount  = COUNT(*) --Includes current node
   FROM dbo.Hierarchy h, 
        dbo.HTally t
  WHERE t.N BETWEEN 1 AND DATALENGTH(SortPath)
  GROUP BY SUBSTRING(h.SortPath,t.N,4)
) --=== Update the NodeCount and calculate both Bowers
 UPDATE h
    SET @LeftBower   = LeftBower = 2 * NodeNumber - HLevel,
        h.NodeCount  = downline.NodeCount,
        h.RightBower = (downline.NodeCount - 1) * 2 + @LeftBower + 1
   FROM dbo.Hierarchy h
   JOIN cteCountDownlines downline
     ON h.EmployeeID = downline.EmployeeID
;
RAISERROR('%u rows have been updated to Nested Sets',0,1,@@ROWCOUNT)
WITH NOWAIT;

RAISERROR('If the rowcounts don''t match, there may be orphans.'
,0,1,@@ROWCOUNT)WITH NOWAIT;

--===== Display the cumulative duration
 SELECT @Duration = CONVERT(CHAR(12),GETDATE()-@StartTime,114);
RAISERROR('Cumulative Duration = %s',0,1,@Duration) WITH NOWAIT;

--===========================================================================
--      Prepare the table for high performance reads by adding indexes.
--===========================================================================
RAISERROR('Building the indexes...',0,1) WITH NOWAIT;

--===== Direct support for the Nested Sets
  ALTER TABLE dbo.Hierarchy 
    ADD CONSTRAINT PK_Hierarchy
        PRIMARY KEY CLUSTERED (LeftBower, RightBower) WITH FILLFACTOR = 100
;
 CREATE UNIQUE INDEX AK_Hierarchy 
     ON dbo.Hierarchy (EmployeeID) WITH FILLFACTOR = 100
;
  ALTER TABLE dbo.Hierarchy
    ADD CONSTRAINT FK_Hierarchy_Hierarchy FOREIGN KEY
        (ManagerID) REFERENCES dbo.Hierarchy (EmployeeID) 
     ON UPDATE NO ACTION 
     ON DELETE NO ACTION
;
--===== Display the cumulative duration
 SELECT @Duration = CONVERT(CHAR(12),GETDATE()-@StartTime,114);
RAISERROR('Cumulative Duration = %s',0,1,@Duration) WITH NOWAIT;

--===========================================================================
--      Exit
--===========================================================================
RAISERROR('===============================================',0,1) WITH NOWAIT;
RAISERROR('RUN COMPLETE',0,1) WITH NOWAIT;
RAISERROR('===============================================',0,1) WITH NOWAIT;
GO