Dr Laura Hill & Bharti Mistry The next generation of risk profiling models … a bold approach to integrating care Dr Laura Hill & Bharti Mistry

Evolution of risk profiling models 2006 PARR Patients at risk of readmission (Hospital Episode Statistics only) CPM Combined Predictive Model ( risk of admission) Primary care, secondary care and activity (planned and unplanned) ACG Adjusted Clinical Groups Correlation of the burden of illness (morbidity and demographics) 2014

Evolution of risk profiling models 2006 PARR Patients at risk of readmission (Hospital Episode Statistics only) CPM Combined Predictive Model ( risk of admission) Primary care, secondary care and activity (planned and unplanned) ACG Adjusted Clinical Groups Correlation of the burden of illness (morbidity and demographics) Combined data Correlational approach 2014

Current intervention emphasis from risk profiling Preventative Early Interventions Targeted Case Management Supported Self Care Based on Health data alone risk of admission Historic analysis and regression algorithms

Crawley and Horsham Mid Sussex CCG application of risk profiling Very high risk of admission High Risk of admission Moderate risk of admission Low risk of admission 1. Proactive care via multidisciplinary teams 2. Tailored health coaching 3. Intensive support, high cost low volume diabetics

Crawley and Horsham Mid Sussex CCG application of risk profiling Very high risk of admission High Risk of admission Moderate risk of admission Low risk of admission Integrated care/ case management Self Management Support

Proactive care – MDTs (integrating care) Structural integration and co-ordinated care

Catalysts for evolving risk profiling beyond risk of admission Integrated care needs Demand and capacity Ageing population Scarce economics Fragmented health and social care Lessons learnt from risk profiling Understanding the potential of combined data Understanding the value of information Lessons learnt from integrated care needs (MDTs)

….realisation

Complex patients Multiple chronic conditions, complications, longevity combined with frailty and resilience, multiple medications, intensive care needs ( health and social care), social isolation

Highlighted need for Intelligence beyond health data alone in risk profiling tools Intelligence driven (combined data) strategies for integrated care planning Outcomes that optimise care, not just reduce risk of admission A correlational approach to quantitative data with qualitative data An algorithm that combines health and social care

…….a bold step.... New generation of risk profiling model developed in partnership with Docobo Includes test social care data Risk factors to complexities Risk factors to social isolation Still includes risk of admission

Film – summarises phase 1 of Integration work

Demographic and risk of admission factors Outcomes sought from integrated intelligence Connectivity to all the factors that makes a patient complex Complex patient Social care factors Health factors ( LTC, medications) Demographic and risk of admission factors Qualitative factors

Example interrogations Social care aggregation examples Utilisation Referrals to social care Demographics Contacts by person Care provision Residential care Nursing care Home care Assessments Support services Nursing home Respite care Carer assigned Costs Payments Budgets Direct Intensity of care Equipment and adaptations Patient long term condition Patient risk of admission

Next Steps 1. Work out relationships between factors contributing to complexity and build into an integrated algorithm (multiple risk model) 2. Understand timelines, demand and capacity in health and social care combined to design integrated care pathways

Evolution of Risk Profiling Models 2006 PARR Patients at risk of readmission (Hospital Episode Statistics only) CPM Combined Predictive Model (risk of admission) Primary care, secondary care and activity (planned and unplanned) ACG Adjusted Clinical Groups Correlation of the burden of illness (morbidity and demographics) H&SC Combined Health and Social Care Data Multiple risk model Combined data Correlational approach Integrated intelligence and relationships 2015

…future of Integration awaits….

laura.hill5@nhs.net bharti.mistry3@nhs.net Dr Laura Hill Clinical Executive Director, Crawley CCG Bharti Mistry Project Manager, Crawley Horsham & Mid Sussex CCGs laura.hill5@nhs.net bharti.mistry3@nhs.net kssahsn.net