Tameside MBC and T&G CCG

Risk Stratification profiles

Briefly describe the initiative/ project/ service

Risk stratification identifies residents risk of acute hospital services from low to high. Risk stratification tools can help determine which people in a population are at high risk of experiencing outcomes, such as unplanned hospital admissions, that are simultaneously: undesirable for patients; costly to the health service; and potential markers of low-quality care. In Tameside and Glossop we have developed risk stratification profiles at neighbourhood level that enable neighbourhood health and social care teams to work with residents and patients in the various tiers of the risk stratification pyramid in a way that meets the needs of the individual. The profiles were developed in a way that enables commissioners to see a pseudonymised profile that they can use to work with GP practices within neighbourhoods- the profiles also provide a dashboard at the back end at GP practice level. The practices can then identify the relevant patients for intervention via their own systems. There are 5 neighbourhoods and for bench marking purposes a high level Tameside and Glossop profile as also been developed.

Why do you think it should win this award?

The profiles support integrated care, reduce demand in secondary care. They help identify residents for a variety of interventions at different levels of need, which over time will hold back the need for more intensive health and social care interventions. The profiles are used currently as part of Tameside and Glossop’s move to integration and will also be used to target residents who will benefit from social prescribing and self care initiatives.

What are the key achievements?

This project as worked because the councils and CCGs intelligence teams are working together as a single intelligence function, so using a wide skill and knowledge set jointly.
The profiles have been successfully received by the GP practices and integrated neighbourhood teams very well, who are using the profiles to make a real difference to patients while supporting the efforts to reduce demand on secondary care.
Please note the example submitted uses dummy data, due to sensitivity of the data