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

The next generation of risk profiling models … a bold approach to integrating care

Dr Laura Hill & Bharti Mistry

2006

2014

Evolution of risk profiling models

2006

2014

Combined data

Correlational approach

Evolution of risk profiling models

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

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

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)

….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

…….a bold step....

New generation of risk profiling model developed in partnership with Docobo

Film – summarises phase 1 of Integration work

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

…future of Integration awaits….

Dr Laura HillClinical Executive Director, Crawley CCGBharti MistryProject Manager, Crawley Horsham & Mid Sussex CCGs

[email protected] [email protected]

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