Hasib Aftab Head of IT & Systems, Camden CCG Risk Stratification

Risk Stratification - Tools Available Risk stratification is starting to be used in a number of areas – e.g. risk of developing a long term condition, an acute episode or a complication For unplanned admissions different tools exist – e.g. PARR ++, Combined Predictive Model, QAdmissions For –National focus on unplanned hospital admission (AUA DES) –Local focus on frailty identification (CCM LCS)

Emis Web Risk Stratification Tool Camden CCG are funding Emis’ Risk Stratification Tool for Camden practices (since July 2014) Tool consists of: –Risk stratification algorithm (QAdmissions) –Supporting searches & protocols on Emis Web –Documentation & guides Integrates directly into Emis – can batch add & review results broken down by risk scores

QAdmissions – further detail Calculates the risk of emergency admission to hospital in next 1 or 2 years Uses coded data from electronic health record (Emis Web) Takes into account a range of factors –Demographics & ethnicity –Location & deprivation –Pre-existing medical conditions –Test results (e.g. BMI, haemogloblin) Calculator & supporting scientific paper available

QAdmissions – recommendations Run at least quarterly Review patients by risk scores Emis categorises these as: –Very high risk > 28% –High risk 18-28% –Medium Risk – 12-18% –Low Risk 7-12% Identify patients for inclusion either on: –Top 2% for AUA DES (NHS England) –Frailty register/CCM LCS (Camden CCG)

QAdmissions & AUA DES The tool is accessible from the Population Reporting module in Emis Web

QAdmissions & frailty register Searches to support the CCM LCS sit in a different folder from the tool (under Camden PCT Information Team)

QAdmissions – where we are at 35 / 37 Camden practices currently using the tool Available to use at least until March 2016 (we’ll review) 960 patients currently on frailty register (April 2015) We are encouraging use of the tool to raise this

QAdmissions – issues Dependent on good quality coded data Only looking at one data source (Emis) Doesn’t refresh automatically – needs to be re-run Focuses on risk of unplanned admission (not risk of frailty / falls) Risk stratification tools are only estimates – they need to be used alongside local clinical knowledge

QAdmissions – support available IT & Systems Team, Camden CCG here to support use of this tool or We can provide – / telephone advice –Training through Practice visits IT Locality Workshops Further step by step guides for using tool also available