Long Term Conditions Risk Stratification
Dr Junaid Bajwa
Conway Medical Centre, Greenwich
About me
GP Principal, Greenwich
RCGP Clinical Commissioning Champion
Associate in Public Health, NHS Greenwich
Medicine’s Management Lead NHS Greenwich
GP Appraiser NHS SEL
Chair Greenwich LMC
Education Lead GPCC
Prepare to Lead alumni, NHS London
Multimorbidity: LTC
– The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions
– More people have 2 or more conditions than only have 1
Most people with any long term condition
have multiple conditions in Scotland
The working lunch…..
Monday
0800am
0810am
0820am
0830am
0840am
0850am
0900am
0910am
0920am
0930am
0940am
0950am
1000am
1010am
1020am
1030am
1040am
1050am
1100am
1110am
1120am
1130am
1140am
1150am
1200pm
1210pm
1220pm
1230pm
1600pm
1610pm
1620pm
1630pm
1640pm
1650pm
1700pm
1710pm
1720pm
1730pm
1740pm
1750pm
1800pm
1810pm
1820pm
1830pm
1840pm
1850pm
1900pm
Tues
Weds
Thurs
Fri
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16 face to face 10 minute appts
Telephone encounters: 5-10
Home visits (2-3)
Referrals: 3 (am)
Review blood tests/Investigations
Post/ Fax/ Email (75-100 letters per day)
16 face to face 10 minute appts
Referrals: 3 (pm)
What about:
QoF/ LES/DES/ CIS/ Additional Services/ Child
Protection/ GSF/ Information Governance/ CQC/ PRG/
Practice Meetings/ KPI’s/ Audit: Research/ Reviewing
Prescribing/ HR issues/ LMC/ Public Health/ CCG
….(+++++++++++)….
Stepping outside the chaos to manage LTC holistically
Proactive, not reactive medicine
GP’s and Nurses in deprived areas
struggle with LTC’s
“Demoralising”
“I feel like a
wrung-out rag
at the end of
consultations”
“Exhausting”
“If you’re too
caring ... you’ll
crack up in a place
like this. Our
boundaries lie
where they are
because they have
to at the moment”
"Commodities are fungible, goods tangible,
services intangible, and experiences are
memorable." (Lee)
Proactive management, not reactive
Self Management
systematic transfer of some knowledge and power to maximise selfmanagement and choice, where the GP acts as a navigator.
Motivating Staff and Patients
Focus on compassion, autonomy, mastery and purpose
(correspondence (personalized, targets individualized), pt experience,
face/face, telephone)
How can we do the right thing, but also make the lives of those around
us easier at the same time
Opportunities & challenges?
‘A pessimist sees the difficulty in every
opportunity,
… an optimist sees the opportunity in
every difficulty’
Sir Winston Churchill
Long Term Conditions Module
Improving the experience of healthcare for
those with long term conditions
Risk Stratification
• The dilemma of "defining risk" for our patients on long-term
conditions
– Is it just the number of registers?
– What about outside Qof: parkinsons, cirrhosis, inflammatory bowel
disease….children….
• Existing:
– Hospital Admission Risk programme (HARP)
High–impact User Manager (HUM)
Patient At Risk of Re-hospitalisation (PARR)
Probability of repeat admissions (Pra) tool
– http://www.yourdiseaserisk.wustl.edu/
Looks at: Cancer/Diabetes/Heart Disease/Osteoporosis/Stroke
– http://www.readmissionscore.org/
Heart Attack/ Heart Failure/ Pneumonia
What if we used what we have?
Metrics
Long Term Conditions
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HbA1c
Cholesterol
BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
Age >75
Being a smoker
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Cancer,
COPD,
Asthma,
Diabetes,
CKD 3,4,5,
Hypertension,
Rh Arthritis,
AF,
HF,
Hypertension,
Mental Health
condition,
LD,
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Dementia,
Parkinsons,
Cirrhosis,
being on the
GSF,
Inflammatory
Bowel Disease,
Stroke/TIA,
Osteoporosis
What if we used what we have?
Metrics
Long Term Conditions
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HbA1c
Cholesterol
BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
(Modifiable)
Being a smoker
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Cancer,
COPD,
Asthma,
Diabetes,
CKD 3,4,5,
Hypertension,
Rh Arthritis,
AF,
HF,
Hypertension,
Mental Health
condition,
LD,
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Dementia,
Parkinsons,
Cirrhosis,
being on the
GSF,
Inflammatory
Bowel Disease,
Stroke/TIA,
Osteoporosis
Age >75
(Fixed)
Within the metric….RAG
Metrics
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HbA1c
Cholesterol
BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
Age >75
Being a smoker
RAG: R-2pts / A-1pt / G-0pt
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G (6.5-7.5), A (7.5-8.5); R (>8.5)
> 4:2: A: 1 pt if above this ratio
(>150/90; if DM/CKD/CHD >140/90) 1 pt if above
G: 3,A: 4, R: 5
G (CKD2 60-89); A (CKD3 30-59); R (CKD4,5 ie < 29)
A: (Obese**) R (:morbid obesity)
A: 1 pt if above norm
R: (>5)
(last recorded within 3m) R: 15-27; A: 5-14
A: 1 point
Repeat medications (>5): A 1 pt if above
A 1 pt if above 75
A 1pts
Managing the chaos: Proactive vs Reactive
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Cumulative totals within each of the categories would then allow a 360°
review of your registered population
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Could you then establish a set of rules re: appointments; removing the
monthly letters for each review/ reduce waste in the system; offer extended
appointments with a focus on self management- improving the patient
experience
Green
Amber
Red
Dr appts
(?around bday)
2/yr
3/yr
4/yr
Nurse appts
3/yr
4/yr
5/yr
MSDi LTC Module
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The software will allocate a R,A,G, status to patients based on:
– The number of long term conditions they have
– Indicators used to define whether those conditions are optimally managed
– No of visits a patient has made to the surgery over the last 12 m
– Flexible: to allow for user defined thresholds and weightings to be allocated
to each of the above parameters
– A care plan will be generated for the patient which will include the number of
appointments that a patient will have over the following 12 m which are
dedicated to the optimal management of that patients conditions.
– The software is practice based
– At locality level anonymised data can be aggregated and accessed through
a web-based portal, allowing risk to be stratified across a geography.
Set-up Rag Rating Criteria
Patient Stratification by No. LTCs
Patients with RAG rating reasons
No. Patient Interactions with in last
12 months
% Patients with No. Diseases by Age
Patients not controlled
PDSA: future add ons
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PDSA cycle
Coding: Number of hospital admissions A(2); R(>3);
Quantify length of stay in hospital
QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20)
QDScore® algorithm calculates your risk of Type 2 diabetes.)
QoL score (would be useful to include this metric- we do not currently
assess this in primary care)
Looking at social determinants of health: e.g. personal/ household income,
social housing, postcode, use of carers, social isolation
“Not all that can be counted, counts. And not all that counts can be counted.”
-- Albert Einstein
Personal Health Plan
Personal Health Plan
Personal Health Plan
Improving the Patient Experience
SDI. 12.GB.107042.SL
Date of Preparation: May 2012
For More Information:
• MSDinformatics Stand 171 in main hall
• Call 01992 455 400
• Email: msdi@merck.com