RISK STRATIFICATION TOOL Diagnosis / Health assessment Stream A Self Care pathway Led by: Patient Primary care Condition stable (blood sugars stable) Individual management targets achieved or improving Compliant with medications and treatment Responding to current management Stream B2 Acute Deviance from Wellbeing (time limited) Shared care (Primary and secondary care) with patient as co-producer Condition has become unstable and has not responded to primary care change in treatment Onset of acute complications Admission to hospital for a related condition Inability to achieve / no improvement towards targets Reduction in independence Stream C Chronic Deviance from wellbeing (Long Term) Led by: Secondary care with primary care and the patient as co –producers Multiple complications Multiple long term conditions Unable to cope / reduction in independence Inability to stabilise condition On maximum treatment Multiple hospital admissions Referral to MDT Referral to MDT