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

2. 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) 2006 2014 Evolution of risk profiling models

3. 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) 2006 2014 Combined data Correlational approach Evolution of risk profiling models

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

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 Scarce economics Understanding the potential of combined data Fragmented health and social care Understanding the value of information Demand and capacity Ageing population Lessons learnt from risk profiling 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 admissionA correlational approach to quantitative data with qualitative dataAn 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 dataRisk factors to complexitiesRisk factors to social isolation Still includes risk of admission

14. Film – summarises phase 1 of Integration work

15. 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. Patient long term condition Patient risk of admission Patient long term condition Patient risk of admission Social care aggregation examples Example interrogations Utilisation Referrals to social care Demographics Contacts by person Care provision Residential care Nursing careHome careAssessments Support services Nursing homeRespite care Carer assigned Costs PaymentsBudgetsDirect Intensity of care Equipment and adaptations

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 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 2006 2015 Combined data Correlational approach Integrated intelligence and relationships

19. …future of Integration awaits….

20. 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