The next generation of risk profiling models … a bold approach to integrating care Dr Laura Hill & Bharti Mistry.
Post on 27-Dec-2015
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The next generation of risk profiling models … a bold approach to integrating care
Dr Laura Hill & Bharti Mistry
Current intervention emphasis from risk profiling
Based on Health data alone risk of admission Historic analysis
and regression algorithms
Crawley and Horsham Mid Sussex CCG application of risk profiling
1. Proactive care via multidisciplinary teams
2. Tailored health coaching3. Intensive support, high cost low volume diabetics
Crawley and Horsham Mid Sussex CCG application of risk profiling
Integrated care/ case management
Self Management Support
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)
Complex patients
Multiple chronic conditions, complications, longevity combined with frailty and resilience, multiple medications, intensive care needs ( health and social care), social isolation
Outcomes sought from integrated intelligence
Connectivity to all the factors that makes a patient complex
Patient long term
condition
Patient risk of admission
Patient long term
condition
Patient risk of admission
Social care aggregation examples
Example interrogations
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
2015
Combined data
Correlational approach
Integrated intelligence and
relationships
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