Risk Stratification: What is it and how do practices use it? Western Bay of Plenty Primary Health Organisation (WBOP PHO) partners with general practice to improve health outcomes for our enrolled population. WBOP PHO supports practices to identify high-risk patients who will benefit from targeted intervention and proactive management. The process of separating patient populations into high-risk and low-risk groups is called risk stratification. Having a tool to classify patients according to risk is key to the success of any population health management initiative. An algorithm was developed nationally to identify patients who are at risk of admission to a hospital facility in the next 12 months. Patients are assigned a score between 0 and 100 based on 16 weighted factors, including history of inpatient admission, age, gender, ethnicity, social deprivation factors, medical history (of chronic conditions), as well as the number of GP visits and ED presentations in the past 24-month period. We have applied this tool to produce risk scores for enrolled patients on a six-monthly basis. The scores are then used to predict the likelihood of a patient being admitted to hospital as a result of known factors. Intervention and proactive management by general practice will reduce the likelihood of ED presentations and unplanned hospital admissions. Analysis of Bay of Plenty District Health Board hospital activity for 2018 confirmed that risk scores accurately predicted patient attendances to ED in three out of four cases for the top 10,000 patients. Unplanned admissions were predicted in six cases of every 10. WBOP PHO has undertaken the third risk stratification for each practice and you can now access a spreadsheet of your practice results on the PHO portal http://portal.wboppho.org.nz/. The next risk stratification analysis will be undertaken in February, with results available in March.
Case Study using risk stratification data Fifth Avenue Family Practice has used the risk stratification data to identify their high-risk MÄ ori population. It found 46 patients considered to be high-risk and will be developing care plans targeting early intervention for all these patients. They will also be enrolling eligible patients in PHO funded management programmes such as CarePlus, developing targeted programmes for mental health and vulnerable children, updating recalls, alerts and referrals, and improving documentation and classifications in clinical notes.
PHO Innovation Project Fund As well as programmes such as Care Plus you can also consider wrapping an improvement project around your high risk score patients. Funding is available within the PHO Innovation Project Fund (application template available from debbiep@wboppho.org.nz.