Transcript Risk stratification

RISK STRATIFICATION TOOL
Diagnosis / Health assessment
Stream A
Stream B2
Stream C
Self Care pathway
Acute Deviance from
Wellbeing (time limited)
Chronic Deviance from
wellbeing (Long Term)
Shared care (Primary and
secondary care) with patient
as co-producer
Led by:
Secondary care with
primary care and the
patient as co –producers
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
•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
•Multiple complications
•Multiple long term
conditions
•Unable to cope /
reduction in
independence
•Inability to stabilise
condition
• On maximum treatment
•Multiple hospital
admissions