Risk stratification is essential to identify at risk patients in order to provide preventative measures to avoid unnecessary admissions and episodes of care. Various risk stratification mechanisms are listed below.
1. Clinical judgement
Clinical judgement is one of the most important mechanisms of identifying and confirming patients who are at risk. The reports and scores below help support this clinical judgement.
Reports can be made on SystmOne and EMIS to identify at risk patients. This could include patients who have had multiple recent A+E/OOH attendances or have frailty recorded but aren’t on your at risk register.
Some example reports are available on SystmOne, to find them go to Clinical Reporting > Wiltshire CCG > Risk Stratification. These reports are already available to Ardens users (Clinical Reporting > Ardens > Meetings > Risk Stratification).
Please copy and amend the reports if needed to help target the appropriate at risk patients. Please also do suggest to us any additional reports that may be useful.
3. Frailty Scores
The electronic frailty index on SystmOne can also identify at risk patients. To use this on SystmOne, go to Reporting > Miscellaneous Reports > Electronic Frailty Index Report.
Once you’ve identified your Top 2% (or whatever value you choose), you may wish to select them all and add a ‘Frailty’ read code. This is so you can then easily identify these patients in Clinical Reporting.
4. Third Party Tools
The ACG and Devon Tools have both been used in the past. Their uptake and continual use has not been as good as hoped. This may be due to the other above three options being easier for GP practices to use. The CCG has therefore decided that GP practices are no longer required to use ACG and do not have to do any data uploads.
These third party tools may have benefits for population based health care. Wiltshire CCG are exploring these possibilities further, but individual practice involvement is not required at present.