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Five steps to planning the risk profiling DES (1 CPD hour)

This is the article only version of this CPD module. Click here for the full CPD module.

With the relentless rise in unscheduled admissions, risk stratification has been seen for many years as having potential to help reduce that tide. With an average hospital stay costing about £3,000 – and for people approaching the end of their lives it can be closer to £7,000 – it is not surprising that both NHS England and CCGs want GPs to take steps to try to reduce admission rates. There is however no real evidence that risk stratification works in this context. It therefore remains to be seen whether this DES will fulfil its objective of reducing avoidable admissions.

What the DES does offer practices is an opportunity to get well positioned for the future. The key for maximising the financial gain will be good working relationships across your primary health and social care team. For more information on whether this DES is right for your practice to undertake, lease see my article on Pulse, DESs 2013/4: Which are worth doing and which aren’t.

This article explains how to undertake the risk profiling DES in five easy steps. You may also be able to use the process to plan the other three new 2013/14 DESs.

1 Get all the information you need from your CCG

Have you received information from your CCG on the risk profiling tool you are required to use for this DES? Do you know what the priority long-term condition is for your CCG? (If not you could probably hazard a reasonable guess if you look at admission rates for various conditions: COPD; falls; the elderly generally). How does your CCG plan to collate information from practices? What kind of return mechanism do they intend to use? If they haven’t told you, ask your medical director, CCG representative, chief operating officer – or all of them!

This DES should not really have taken anyone by surprise but the service specification from NHS England is overwhelming in its breadth but short on detail, creating a major challenge for CCGs as well as practices. It is now June and many practices have yet to get the required detail from their CCG.  The deadline to agree this with your CCT is 30 June. It is important that you log when you have asked for this information and who you have asked. Keep a record. You may need this to ensure you get payment. Practices should not be penalised for their CCGs’ failure to provide the required information by the deadline.

2 Run the risk profiling tool

The use of risk profiling/stratification to reduce unscheduled admissions has been tried in England for at least five years, with several tools used. There are two outdated DH-commissioned tools that were employed in many areas:  PARR (patients at risk of re-hospitalization) and the combined predictive model (CPM). These are both now out of date and need upgrading but there are no plans for the DH to commission the upgrades.

There are also a variety of commercially available tools developed by various private companies. These have varying strengths and weaknesses. Some former forward-thinking PCTs have evaluated these systems and the results can easily be found online. Other PCTs updated the CPM for local use prior to their demise. It is not unusual for a proportion of those identified by these models as being ‘at risk’ to have died by the time the multidisciplinary team meeting takes place. Few tools use real time data.

Consent is a further issue when considering tools. I am not aware of any computer-based model that offers the opportunity for patients to opt in or out of risk profiling. Practices may wish to consider consent issues with a medicolegal defence organisation.

Some of you may well think the best approach would be to draw up a list with the district nursing team of those patients you collectively feel are at highest risk. It would be likely to have a good deal of overlap with the list produced by any other tool. However, it is not a systematic approach and could exclude unknown, and therefore unmet, need. The majority of computer-based tools are good at identifying those at significant (imminent or urgent) risk of hospital admission but are poor at picking up those at emergent risk. EARLI developed by Castlefields medical practice (Lyon, 2007) a few years ago is a very sensitive but non-specific tool for identifying risk of hospital admission in the elderly patient group.

It would be prudent to adopt a combined approach to risk profiling. If a tool is available, use it to identify those at most urgent risk. These are the patients for whom you will be expected to provide evidence of management today – but don’t neglect those at emergent risk. They are tomorrow’s case-managed patients. It’s worth noting that one of the aims of the DES is to encourage practices to undertake risk stratification of their registered patients on at least a quarterly basis. The documentation is not specific about which population: Is it your registered list? A cohort of patients with long-term conditions? A cohort identified by the CCG? Be prepared for any of the above – I suspect this population-focused, GP-led approach to risk stratification will be around for some years so it may well pay to put your practice on the front foot.

Lastly, and most importantly, ensure the practice IT/clinical lead is confident with the application of the tool.

3 Set up multidisciplinary team meetings 

The DES is explicit: practices are required to ‘coordinate with other professionals the care management of those patients who would benefit from more case management’. Approach your local community teams. Whom you invite to a meeting is not stipulated but the key players have to be your district nursing team. Other key people to invite might include occupational health and physiotherapy colleagues. Social care workers can also offer valuable assistance and local pharmacists can offer insight. If you haven’t got a room big enough in the practice, you could run the meeting virtually.

Depending on which tool you have used to identify at-risk patients and what population you have stratified, I would then ‘RAG rate’ your list:

·         Red to identify those at most significant risk. These are the patients for whom a care plan is required within the context of the DES

·         Amber for those you think could end up in hospital but may not

·         Green for those you think have a low risk of admission.

This is where multidisciplinary team working can be at its strongest. The combined clinical knowledge is key.

From the DES point of view, the important thing is to schedule a list of meetings and record who has been invited and attended. You will need this, together with minutes with action points as evidence of a multidisciplinary approach.

Initially, monthly meetings would seem reasonable. Not all GPs in the practice need attend; this would be too costly.

4 Co-ordinate a schedule of practice meetings

A GP or senior practice nurse would be ideal practice coordinator of care but it is vital that the whole practice team understands the aims of the DES and what clinical information needs to be collated to achieve maximum payments. Running an initial lunchtime meeting on this DES could increase understanding. Focus on the data that needs to be collated. Communicating with colleagues in-house about the patients they see regularly and the actions they have already put in place to prevent admission might prove simpler than it first appears. It may be as simple as ensuring the correct Read codes are entered on the system for that patient.

For example, your GP partner knows Mrs. C very well; she is on optimal management for her COPD and angina, has good family support and is case managed by the community respiratory nurse and district nursing team. But has she had all her medication and LTC reviews? Are they all recorded on the computer?

Think QOF points here too. The patient may be receiving palliative care and in the last few weeks of life. This is a justifiable patient exception. Is she on your palliative care register? Has she been exception reported?

If a patient flagged up by your tool is not known to the multidisciplinary team, then an assessment will need to be made. Who does that assessment and where is a consensus decision for the team but a holistic nurse or GP review is usually required.

Questions worth considering would be:

·    Is the patient on any LTC register? Have they had a recent condition review?

·    Is a medication review due? Have interactions and side-effects been considered. Has one been done in the last year?

·    Have they had a dementia screen? This may links to the new dementia DES. A screening tool like 6CIT might help enhance your payments for that DES.  Have they had a depression screen? The four-item Geriatric Depression Score tool is another useful screen.

·    Is there an identified enduring mental health issue?

·    Are there any social care issues known? Are there any carer’s issues?

·    If the patients is elderly, consider falls and continence issues.

Ensure that there is a named coordinator of care e.g. practice, district nurse, social care. Record the plans for managing that patient once an assessment has been made:

·    Does the patient know who to call when?

·    Do they have rescue medication, if appropriate?

·    Are there crisis plans in place with health and social care?

Also start recording the action you have taken to support that patient (use Read codes) e.g.:

·                     referral to memory clinic

·                     referral to community geriatrician

·                     referral to community falls team

·                     referral to counselling

·                     referral to social care

·                     referral to self-care group/disease management group.

5 Create a Read-coded template

Provide all multidisciplinary team members and the practice team with a shortlist of preferred Read codes. The template should capture evidence of intervention and all healthcare staff should be able to access.

Collate the care plan information into a template. Most computer systems offer this functionality. Create your own template or ask a neighbouring practice whether they have used a template or devised one. Read codes don’t exist for everything you may wish to code so you may have to use some proxy codes. I understand some new Read codes for care planning are expected to be made available this autumn.

Dr Eithne Cummins is a GP partner in Sheffield.

Further reading

Goodwin, C. R. (2000). Managing people with long term conditions, GP Enquiry Paper. The Kings Fund.

Lyon, L. D. (2007). Predicting the likelihood of emergency admission to hospital of older people:develpment and validation of the Emergency AdmissionRisk Liklihood Index, EARLI. Family Practice , 24(2):158-167.

Miller, R. a. (2000). Risk Stratification .Apractical Gude for Clinicians. Cambridge.

NHS England, C. B. (n.d.). Enhanced Service Specification, Risk Profiling and Care Managment Scheme.