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Risk Stratification. Sadie Bishop & Wayne Douglas – GCCG Chetan Modha - Sollis. Agenda. Overview: What is Risk Stratification. Use of clinical judgement, clinical thresholds and/or statistical techniques i.e. predictive modelling, to - PowerPoint PPT Presentation
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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
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