1. 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