Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom.

Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom.
BMC Emerg Med 21, 55 (2021). https://doi.org/10.1186/s12873-021-00450-2

• A review of the entire pathway of care of patients (n=552) whose death was registered in Salford during the 8 week period of the first wave (primary care, secondary care, 111 and 999 calls) was carried out in order to create a single record of healthcare prior to death. 
• 18% of deaths contained themes consistent with some degree of avoidability. In people aged ≥75 years who lived at home this was 53%, in care home residents 29% and in patients with learning disability 44% (n = 9). Common themes were; delays in patients presenting to care providers (10%), delays in testing (17%), avoidable exposure to COVID-19 (26%), delays in provider response (5%), and sub-optimal care (11%). For avoidability scores of 2 or 3 (indicating more than 50% chance of avoidability), 44% of cases had > 2 themes.

Proactive care frameworks (UCLP)

Proactive care frameworks
University College London Partners (UCLP)

• UCLP have developed a series of proactive care frameworks to support primary care teams to manage patients with cardiovascular and respiratory long-term conditions. It includes search and risk stratification tools, workforce education and training and digital resources.
•  Press release: Post-COVIDrecovery: proactive care, self care and CVD prevention

Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use.

Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use.
Br J Gen Pract. 2020 Oct 1;70(699):e740-e748. doi: 10.3399/bjgp20X712793. PMID: 32958534; PMCID: PMC7510844.

• To describe availability and use of Early Admission Risk Stratification (EARS) tools across the UK, and identify factors perceived to influence implementation. An online survey identified 39 different EARS tools in use. Nearly 40% of areas using EARS tools reported introducing or realigning services as a result, but relatively few reported use for service evaluation.

Precision public health – A critical review of the opportunities and obstacles.

Precision public health – A critical review of the opportunities and obstacles.
EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London, September 2020

• The term ‘precision public health’ (PPH) refers to a new approach in public health which involves the use of novel data sources and/or computer science-driven methods of data analysis to predict risk or outcomes, in order to improve how interventions are targeted or tailored, with the aim of making them more individualised and therefore more effective and cost-effective than methods currently in use. This critical review outlines key assumptions underpinning the PPH approach and identifies potential challenges in its application.

Long-term condition support - tools and resources

Long-term condition support - tools and resources
UCL 9 June 2020

• This site contains tools and resources designed to enable primary care teams to continue to effectively manage patients with long-term conditions. Includes:
• Search and risk stratification tools that can be used with EMIS (and SystmOne to follow),  accompanied by user guidance.
• Education and training resources including protocols, guidance, videos and virtual training sessions to upskill the breadth of primary care team members to proactively support patients.
• Digital tools - A selection of a clinically appraised digital tools to support patient activation and self-management in the home setting.
• See blog Support for long-term condition management during and after COVID-19 

A predictive risk stratification in primary care increases hospital activity

Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial
BMJ Qual Saf 2018. doi: 10.1136/bmjqs-2018-007976

• Introduction of a predictive risk stratification model (PRISM) into 32 general practices in Wales  resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

Abstract

Targeting the ‘right’ patients for integrated care

Targeting the ‘right’ patients for integrated care: stakeholder perspectives from a qualitative study
Journal of Health Services Research & Policy v23(4) p243-251, 1 October 2018

• Secondary analysis of qualitative interviews with relevant stakeholders from two integrated care sites in England found that the data-driven approach to targeting patients, recommended in the policy literature, did not align with stakeholders’ experience of selecting patients in practice. The ‘right’ patients were at lower risk than those recommended by policy, and their complexities were identified as comprising mostly social rather than medical issues.

Population Health Analytics and new models of care ACO Johns Hopkins- NHS Expo

The Importance of Population Health Analytics to the Development of New Models of Care
NHS Expo September 2018

• Presentation from Johns Hopkins Healthcare Solutions ACG team outlining existing available population health data, importance of analytics, link to outcomes,  identification of high risk groups and how this can lead to "intelligent commissioning". 
• Contents:
• 1. Intelligent commissioning: making better decisions based on new insights
• 2. Redesigning care: evidence-based improvement
• 3. How population health analysis engages clinicians
• 4. Supporting the spectrum of needs: from prevention thru complex care

Predictive risk stratification model (PRISM)

Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC).
Health Serv Deliv Res 2018;6(1)

• Evaluation of the effects of introducing Predictive RIsk Stratification Model (PRISM) into 32 general practices in south Wales. 
• Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital, ED attendances, GP event-days, outpatient visitsand time spent in hospital. PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase.

See also
Snooks H, Bailey-Jones K, Burge-Jones D, et al
Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial
BMJ Qual Saf Published Online First: 05 November 2018. doi: 10.1136/bmjqs-2018-007976

Abstract

Using risk stratification in new care models to identify vulnerable patients

Protecting our most vulnerable patients
NHS England blog 27 September 2017

• Analysts at NHS England have looked at the approaches taken by five new care model vanguards (Tower Hamlets, Sunderland, North East Hants and Farnham, Erewash and Morecambe Bay) to identify patients at risk in their communities. They found that they have introduced the ‘building blocks’ of an effective risk stratification process and most are using predictive models and implementation is clinically-led.
• Full findings on risk stratification are included in a Learning and Impact Study from the Operational Research and Evaluation Unit, NHS England (england.oret@nhs.net).

Risk Stratification for Population Health Management: Vanguard learning product

Risk Stratification for Population Health Management: Vanguard learning product
NHS England September 2017

• This product draws on the learning from vanguard sites to offer advice and guidance to staff within local healthcare systems who want to find out more about how risk stratification can be used to support population health management.
• The guide includes:
• An introduction to risk stratification and population health management.
• Examples of risk stratification for population health management in practice in vanguard sites, including tools, methods and outcomes.
• Collective lessons learned across vanguards that have used risk stratification for population health management.
• An overview of the three NHS predictive modelling tools in risk stratification.
• Links to other key resources, including:
• Evidence for risk stratification as a tool for supporting care planning and personalised care.
• A learning and impact study on risk stratification.
• A case study on the use of risk stratification to identify patients who are potentially suitable for extensive care and enhanced primary care.

Risk stratification: Learning and Impact Study

Risk stratification: Learning and Impact Study
Operational Research and Evaluation Unit, NHS England, July 2017
(Available on request - England.ORET@nhs.net. See Protecting our most vulnerable patients, blog by Charles Tallack, Head of the NHS Operational Research and Evaluation Unit, (27 September 2017) )

• Risk stratification forms a core part of the Multispeciality Community Provider (MCP), Primary and Acute Care System (PACS), and Enhanced Health in Care Homes frameworks.
• Risk stratification is used to predict future adverse events, such as unplanned hospital admissions, and by healthcare systems to ‘case find’ those individuals at risk of such an adverse event and for population health planning.
• This report presents the benefits, what works, and what doesn’t, in implementing risk stratification and the implications for others thinking about taking up risk stratification.
• It draws on findings from: five case study visits to MCP and PACS vanguards; a brief literature review; and consultation with senior stakeholders.

Whole Population Management

Whole Population Management: Opportunities and how to realise them
Conrane IHS 7 April 2017

• This briefing examines how Whole Population Management can progress the objectives of STPs using an Accountable Care Organisation model. 
• Central to the model is use of a risk stratification prediction model, such as ACG, to support patient identification and enrollment.
• The report outlines core workforce roles with indicative job contents, decision support tools used,  and how the model could work at a locality level within the NHS using a hub and spoke model (30-50k population)

Building bridges, breaking barriers: Integrated care for older people

Building bridges, breaking barriers: Integrated care for older people
CQC 13 July 2016

• This report looks at how well care for older people is integrated across health and social care, as well as the impact on older people who use services and their families and carers.
• Recommendations:
• Health and social care leaders should develop and agree a shared understanding and definition of what integrated care means for the population in their local area, and then work towards delivering this shared aim.
• NHS England and Association of Directors of Adult Social Services should lead on developing an agreed methodology and data set for identifying people at risk of admission to secondary care or deterioration.
• Older people should be meaningfully involved in making informed decisions about their care needs and care planning – in particular about the outcomes that are important to them – based on the existing national and local guidance.
• Commissioners and providers in an area should ensure that information and support for older people and their families or carers is available, and this sets out connections between services, and how the people's accessibility needs will be met.
• The National Quality Board, in partnership with the National Information Board, develop and share a set of validated data metrics and outcomes measures for integrated care with person-centred outcomes at the heart of decision making about service provision and based on a consistent, shared view and definition of integration.

Beyond risk stratification

Segmenting Populations to Tailor Services, Improve Care
Quality Matters, Commonwealth Fund, June 2015

• An examination of the efforts of health care organizations to go beyond risk prediction into other sources of information—including clinicians’ observations, data on consumer habits, and social factors—to create more nuanced segmentation approaches.
• It describes work by Denver Health, Kaiser Permanente and Montefiore Health System to take into account patients’ social and economic status and clinicians judgements to help them to determine which patients might benefit from specific team-based care and case management service.

Acute care models - learning from other countries

Exploring international acute care models
Monitor 4 December 2014

• Monitor has looked at international acute service line models to help inform the thinking on potential new models of acute care in the NHS.
• They identified three individual service models that could offer benefits if used more widely by the NHS:
• the value of ‘risk tiering’ for maternity and paediatric services; 
• the importance of technology, particularly to deliver care remotely; and 
• the role out-of-hours care delivered by GPs can play in providing urgent care.

Risk Stratification assurance

Risk stratification assurance
NHS England, 5 February 2014

• NHS England has gained approval from the Clinical Advisory Group in its application for the disclosure of commissioning data sets and GP data for risk stratification purposes to data processors working on behalf of GPs.
• This approval applies to the use of GP and Secondary User Services data, not disclosure of social care data for risk stratification
• NHS England has given an undertaking to the Secretary of State for Health to seek assurance from eligible organisations and to provide a register of approved organisations for the receipt and processing of the patient data for this purpose.
• Annex 2 – Named Register of Existing Risk Stratification Suppliers
• Annex 3 – Risk Stratification Checklist
• Annex 4 – Excluded data

Risk stratification - the information governance framework

Information Governance and Risk Stratification: Advice and Options for CCGs and GPs
NHS England, 14 June 2013

• This document describes the options for GPs and CCGs to continue to perform risk stratification
• an explanation of the information governance issues relating to risk stratification
• a checklist of steps that GP practices, CCGs, and other organisations involved in risk stratification should undertake to comply with the law (see page 13)
• options that CCGs can use in order to conduct risk stratification legally