In this slideshow, Bethan George, Deputy Director Integrated Care of the WELC Care Collaborative describes practical risk stratification and clinical case finding in the WELC pioneer programme. Bethan describes the work they have done with risk stratification for the local population in Waltham Forest, East London and The City. Bethan George spoke at the Nuffield Trust event: The future of the hospital, in June 2014.

1. Practical Risk Stratification and Clinical Case
Finding in the WELC Pioneer Programme

2. The WELC System
A snapshot of the health needs in WELC:
• Deprivation is twice as high as the national average.
• Half of the population belong to Black, Asian, and minority
ethnic communities.
• 30% of the population changes annually. The population is
expected to grow twice as fast as the national average.
• The number of people over 65 is projected to increase by seven
per cent by 2016.
• Birth rates are 40% higher than the national average.
• Hospital stays for alcohol and substance misuse are up to 50%
higher than the national average.
• Newham and Tower Hamlets have the second and third highest
levels of emergency admissions for psychosis in London.
We want to deliver at scale and
pace to achieve radical
transformation across WELC
By shaping the local health
economy around the patient
By changing behaviours across
the system
By developing the provider
landscape

4. 4
Very
High Risk (0.5%)
High Risk (4.5%)
Moderate Risk
(15%)
Low Risk (30%)
Very Low Risk
(50%)
46,300
148,600
267,200
437,800
4900
000's People
10%
32%
36%
22%
% of acute costs
78%
Who are we targeting for integrated care ?

5. Qadmissions (Newham and Tower Hamlets)
• Commissioned by THPCT from Qresearch
(www.qadmissions.org)
• Modelled on a population of 2.8 million patients with
data from 131 PCTs across all 10 SHA in England;
• Validated using two separate populations with 3.5m
patients in total.
• Has been integrated into EMIS – but caution.
• Updated annually
• http://bmjopen.bmj.com/content/3/8/e003482.full
• Open source
Combined predictive model (Waltham Forest)

6. Qadmissions
• Age, Sex, Ethnicity, Postcode, Strategic health authority
• Smoking status, Alcohol status
• Diabetes (type 1 or type 2)
• Heart attack, angina, stroke or TIA?
• Atrial fibrillation?
• Congestive cardiac failure?
• Chronic renal disease?
• Venous thrombo‐embolism?
• Cancer?
• Asthma or COPD?
• Falls?
• Epilepsy?
• Manic depression or schizophrenia?
• Malabsorption (eg Crohn's disease, ulcerative colitis, coeliac disease, steatorrhea,
blind loop syndrome?)
• Chronic liver/pancreatic disease?
• Emergency admissions in the last year: none one two three or more

7. Governance
Sometimes life hits you in the head with a brick.
Don't lose faith.
Steve Jobs

8. Data
Processor
(eg NEL
CSU)
Data Controller
(Acute Provider
BH)
Data Controller
(GP)
Data Controller
(MH Provider –
ELFT)
Data Controller
(Social Services
Provider –
LBTH)
Data Controller
(CHS Provider –
BH)
Governance
• All data controllers take part in a
Governance Group (might be a
subcommittee of the Provider
Collaborative Boards – needs to be
accountable to someone ?)
• The data processor can only ever act
on instruction from the data
controllers
• The data processor will not share any
data from the data controllers with
any of the other partner data
controllers unless it is described in a
sharing agreement or an amendment
to that agreement agreed by the
Governance Group
• The data processor will not share any
data from any of the partner data
controllers with any other
organisation without the permission
of the Governance Group.
Data Processing
Contract
Information
Sharing
Agreement

9. Fair Processing
• Template strategy produced for all partners
• Materials being packaged – NELCSU including
– Poster
– Leaflet
– Animation

10. Be really clear about each problem you are
trying to solve and why it’s important

11. What are we commissioning for integrated care ?

12. How are these scores used clinically
• Target population
– Monthly review of the data – GP led
– Enrolment of patients into care co‐ordination services
– Consent for information sharing
– 13/14 Top 0.5% (VHR), 14/15 Next 4.5% (HR), 15/16 to 20%
(Moderate)
• Outcomes
– CQUIN Indicators
• Total bed days
• Non‐elective admissions
• Avoidable emergency admissions
• Readmissions 30 days
– KPIs

13. Consent