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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
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Risk Stratification Sadie Bishop & Wayne Douglas – GCCG Chetan Modha - Sollis
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
DES Parameters • 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.
