Risk Stratification

Sadie Bishop & Wayne Douglas – GCCG

Chetan Modha - Sollis

Agenda

Arrival & Refreshments

• Welcome and Introduction SB/WD

• Overview: Risk Stratification in GCCG• DES Requirements

SB/WD

• Introductory Presentation to the Risk Stratification System

CM

• System Demonstration CM

• Questions & Answers All

Overview: What is Risk Stratification

Use of clinical judgement, clinical thresholds and/or

statistical techniques i.e. predictive modelling,

to

identify individuals (case finding) or groups of patients

(cohorts)

with

an increased risk of unwanted outcomes who would

most likely benefit from targeted interventions (e.g. case

management).

What has GCCG done to date?

• October 2012 – NHS Gloucestershire/ NHS Swindon procured Risk Stratification Tool from Northgate/Sollis – Clarity Adjusted Clinical Group (ACG) Tool

• May 2013 – 3 pilot practices identified to test tool and inform DES requirements:– Avenue Surgery, Cirencester– College Yard & Highnam, Gloucester– Barnwood Surgery, Gloucester

• June 2013 – Agreed localised DES requirements with NHS England & GCCG Governing Body

• July 2013 – Commence DES rollout with GP practices

Risk Profiling DES• 74p per patient

• DES Specification

– the GP practice carries out on at least a quarterly basis risk profiling of its registered patients

– the GP practice works within a local community multi-disciplinary to assess the list produced by the ACG Tool to inform the care management of patients.

– the GP practice works within the community multi-disciplinary teams to achieve a shared and integrated approach to the case management of each patient to improve the quality of care and reduce their individual risk

– there is a nominated lead professional who is responsible for each patient identified for case management whose role includes undertaking a review and care planning discussion with the patient at a frequency agreed with the patient.

DES Timetable

• Notify NHS England of their participation in the Risk Profiling DES (by June 2013)

• Utilise the Risk Stratification Tool to generate patient lists for MDT review (September 2013)

• Meet with their local MDT to discuss the generated patient lists and identify those suitable for case management (October 2013)

• On-going Arrangements

Q2 - Patient Submission Form to GCCG Friday 8th November 2013

Q3 - Patient Submission Form to GCCG Friday 31st January 2014

Q4 - Patient Submission Form to GCCG Monday 31st March 2014

DES ParametersParameters to be selected in tool To be reviewed

All patients

5% of generated list to be reviewed

Top 5% of patients based on difference between current and predicted risk score

• Based on the parameters an average sized practice (circa. 7,300 patients) will generate a list size of approximately 18 patients for review.

• Practices Complete:• MDT Meeting Patient Proforma: an optional form that provides

practices/MDT with structured questions and provides an aide memoire for data capture.

• Patient Review Submission Form: a mandated form that provides the CCG with anonymised patient review data including outcomes and next steps for the patient.

% of Patients No. of Patients

% of Cost Nature of Morbidity Potential Intervention

1%

100

10% High Risk – Multiple LTCs, frail, social care needs, unstable, end of life

Intensive Case Management

4%

400

17% High Risk – Multiple LTCs, less unstable, some social care needs

Case Management & Disease Management

15%

1500

25%

Moderate Risk – One or two chronic illnesses and/or risk factors. Health likely to deteriorate over time.

Case Management, health coaching & lifestyle management

80%

8000

48% Low Risk – Morbidity due to time limiting or acute illness rather than chronic conditions.

Health education, health promotion & prevention strategies, lifestyle change programme

Risk & Cost Distribution – GP Practice with 10,000 patients