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

The next generation of risk profiling models … a bold approach to integrating care. Dr Laura Hill & Bharti Mistry. 2006. Evolution of risk p rofiling models. 2014. 2006. Evolution of risk p rofiling models. Combined data. Correlational approach. 2014.

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

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

  2. 2006 Evolution of risk profiling models 2014

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

  4. Current intervention emphasis from risk profiling Based on • Health data alone • risk of admission • Historic analysis and regression algorithms

  5. Crawley and Horsham Mid Sussex CCG application of risk profiling 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 Integrated care/ case management Self Management Support

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

  8. 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)

  9. ….realisation

  10. Complex patients Multiple chronic conditions, complications, longevity combined with frailty and resilience, multiple medications, intensive care needs ( health and social care), social isolation

  11. Intelligence beyond health data alone in risk profiling tools Intelligence driven (combined data) strategies for integrated care planning Highlighted need for Outcomes that optimise care, not just reduce risk of admission Acorrelational approach to quantitative data with qualitative data An algorithm that combines health and social care

  12. …….a bold step....New generation of risk profiling model developed in partnership with Docobo

  13. Film – summarises phase 1 of Integration work

  14. Outcomes sought from integrated intelligence Connectivity to all the factors that makes a patient complex

  15. Example interrogations Social care aggregation examples Patient long term condition Patient risk of admission

  16. 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

  17. 2006 Evolution of Risk Profiling Models Combined data Correlational approach Integrated intelligence and relationships 2015

  18. …future of Integration awaits….

  19. Dr Laura HillClinical Executive Director, Crawley CCGBharti MistryProject Manager, Crawley Horsham & Mid Sussex CCGs laura.hill5@nhs.net bharti.mistry3@nhs.net kssahsn.net

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