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

2. 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

3. 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

4. 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

5. 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

6. 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

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

9. 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)

10. ….realisation

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

12. 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

13. …….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

14. Film – summarises phase 1 of Integration work

15. 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

16. 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

17. 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

18. 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

19. …future of Integration awaits….

20. 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
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