Transcript 6. Proactive Care - The next generation of risk profiling

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)
2014
Combined
data
Correlational
approach
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
1. Proactive care via
multidisciplinary teams
High Risk of
admission
Moderate risk of admission
Low risk of admission
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
Integrated care/ case
management
High Risk of
admission
Moderate risk of admission
Low risk of admission
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
Outcomes sought from integrated intelligence
Connectivity to all the factors that makes a patient
complex
Social care
factors
Qualitative
factors
Complex
patient
Demographic
and risk of
admission
factors
Health
factors
( LTC,
medications)
Example interrogations
Social care aggregation examples
Utilisation
Patient long
term
condition
Referrals to
social care
Care
provision
Support
services
Residential
care
Nursing home
Nursing care
Patient risk
of admission
Demographics
Payments
Budgets
Respite care
Home care
Contacts by
person
Costs
Assessments
Direct
Carer
assigned
Intensity of
care
Equipment
and
adaptations
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)
Combined data
ACG
• Adjusted Clinical Groups
• Correlation of the burden of illness (morbidity
and demographics)
H&SC
• Combined Health and Social Care Data
• Multiple risk model
2015
Correlational
approach
Integrated
intelligence and
relationships
…future of Integration awaits….
Dr Laura Hill
Clinical Executive Director, Crawley CCG
Bharti Mistry
Project Manager, Crawley Horsham & Mid
Sussex CCGs
[email protected] [email protected]
kssahsn.net