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South Central Primary Care Trust Alliance

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Risk Stratification and Predictive Modelling to Support Commissioning

and Case Management

How the ACG System is being used in South Central

Alan Thompson ACG Programme Manager

13th June 2012

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South Central Primary Care Trust Alliance

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Objectives of This Session

To give an overview of the background to the work in South Central to roll out the use of risk stratification and predictive modelling to support commissioning and case management activities

To provide a high level overview of the infrastructure that exists in South Central

To present several examples of the benefits that have been realised through the use of risks stratification and predictive modelling in South Central

To share the lessons being learnt

To briefly discuss our next steps

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South Central Primary Care Trust Alliance

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Background

In 2009 the nine PCTs in South Central decided to provide some commissioning functions collaboratively

A requirement was identified for additional analytical capacity and capability to supplement existing analytical and business intelligence functions which was procured via the FESC framework and a contract for the provision of the Commissioning Enablement Service (CES) began in January 2010

The CES provides additional analytical capacity to support three key areas of commissioning: health needs analysis, service redesign and provider management

Our requirements for a risk stratification and predictive modelling tool has been met by the use of the Johns Hopkins University Adjusted Clinical Groups (ACG) tool

The ACG system has been deployed using a single, large scale technical solution. Currently over 40% of the populations’ data are feeding into the ACG system.

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South Central Primary Care Trust Alliance

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High Level Overview of the Infrastructure that Supports Access to Risk Stratification Information

Automated extraction of primary care data from GP Practice System

Secondary care

activity data from

SUS

Data combination, mapping & prep for upload

ACG Grouper

Data repository & reporting

tool

Training

Allocation of User

Names & Passwords

Reference Data

Direct Web Based Access to Tool via Desktop PC

Secure Environment

Data into and out of server via N3 connection

Access to a Series of Standard Reports

Access to ‘Hypercubes’ for bespoke,

multi-dimensional

analysis

Informing patients

and managing potential opt out

Series of IG related processes that comply with all current regulations and guidance

A complex end-to-end infrastructure that took over 9 months to put in place but: • It addresses all of the issues/concerns/requirements of our stakeholder group particularly

around the issue of transferring, storing and sharing data, particularly primary care data • The headache that is primary care data extraction is undertaken by a specialist company

rather than PCT staff • End users have access to a user-friendly graphical interface on their desktop • It only takes 4-6 weeks from a GP practice opting in and having access to ACG

information

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South Central Primary Care Trust Alliance

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Progress Over the Last 21 Months

Over 240 practices across 20 CCGs and all nine PCTs now have access to risk stratification and predictive modelling information about their populations

This covers a population of about 1.9 million people

The roll out programme is accelerating as GPs see colleagues using the tool to support the primary care agenda and to derive benefits

In most cases, the first aspect of the ACG tool that GP Practices and CCGs engage with is the case management element (using the predictive modelling functionality).

However, there are three other areas of the primary care agenda that PCTs and CCGs are using the ACG tool to support – namely risk stratification of the population, disease profiling and resource management

Status of Roll Out Programme – No. of GP Practices by PCT

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South Central Primary Care Trust Alliance

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Risk Stratification

•Stratification of patients into iso-resource groups

•Provides understanding the case mix of a practice, CCG and PCT population

•Helping to identify gaps between service provision and health need

•Supporting commissioning decisions

Resource Management

•Understand differences in case mix between different practices

•Combine with other indicators such as referral rates to create ‘balanced scorecard’ based on disease burden

•Use of pharmacy outputs to support medicines management agenda

•Benchmarking between practices

Case Management

•Flags likely high risk, high cost patients

•Has other markers such as ‘hospital dominant count’ that allow targeting of patients

•This is the functionality being most used at the moment

ACGs

Disease Profiling

•Allocates patients to one or more of 264 disease categories to facilitate disease profiling

•Profiling can be done at practice, locality or PCT level

•Public Health very interested in this aspect as it can support JSNA

The Four Key Areas that ACG Outputs Are Supporting

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South Central Primary Care Trust Alliance

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Risk Stratification (1)

Risk Stratification

Resource Management

Case Managemen

t

ACGs

Disease Profiling

• In the top graph costs are increasing almost exponentially with the number of chronic conditions patients have

• This is one of facts that most surprises people

• The bottom graph confirms that for a population, small numbers of patients consume disproportionate amounts of resource

• In this population in South Central, the 5% of patients with the highest risk scores consumed about 28% of resources in the previous year

• A lot of the analysis being undertaken is confirming what is already known about LTCs …... but it’s always more powerful when it’s done with people's own data

• And it’s providing a level of detail that has not been available before

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South Central Primary Care Trust Alliance

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Risk Stratification (2)

Risk Stratification

Resource Management

Case Managemen

t

ACGs

Disease Profiling

Very High High Moderate Low Healthy Non Users

• There is often significant variation in case mix between practices across a CCG

• This is either confirming or challenging views about variation in case mix or dependency between practices

• This analysis replicates a piece of work undertaken by the Scottish School of Public Heath that demonstrated that multi-morbidity is common in Scotland

• The patterns in this population in South Central are very similar

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South Central Primary Care Trust Alliance

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Disease Profiling (1)

Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

• The ACG outputs are being used to understand the patterns of multi-morbidity within practice and CCG populations

• For example, only 5% of patients with COPD only have COPD whereas over 40% of patients with COPD have at least another 4 chronic conditions

• At both a CCG and PCT level people are beginning to look at the ACG outputs to improve their understanding of disease prevalence

• In this example, Oxfordshire have created a pivot chart that compares SMRs for practices within a locality by each of the 264 disease groups within the ACG System

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• This kind of report is helping people understand that not every individual with an LTC like COPD has the same kind of morbidity burden

• Where programmes to support specific LTCs exist, this information is being used to target the highest risk patients

Risk & Disease Profiling in Combination

Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

• The information gleaned from risk and disease profiling is beginning to inform PCT and CCG commissioning decisions

• In Oxfordshire, the ACG tool to risk stratify whole population to inform a business case for the future development of community matron services

• In Southampton, risk stratification is being used within their ‘Out of Hospital Care’ project to understand the health needs of the top 5% (rather than the current top 1%) and how these can be met by community and primary care services rather than secondary care services

• Risk profiling and disease profiling information is proving useful in getting commissioners thinking about moving away from programmes of care aimed at single diseases to approaches that support the whole individual

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South Central Primary Care Trust Alliance

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Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

Case Finding for Community Matrons and Other Primary Care Services

• There are many of examples of how ACG outputs are supporting case management and Community Matron activities

• Each PCT/locality has developed it’s own criteria for identifying patients who may be suitable for their services – the starting point is the list of 5% of patients with the highest predictive risk scores but they then filter this list using some of the other markers such as:

• The number of long term conditions that a patient has

• The number of conditions strongly associated with hospitalisation

• The presence of diagnoses associated with frailty

• A common theme running through these examples is that whilst there is a lot of overlap between the ACG generated lists and the exiting case management lists, additional, suitable patients are always identified

• No team is using the ACG generated lists in isolation – they are being used as an adjunct to existing referral processes

Case Management (1)

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South Central Primary Care Trust Alliance

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Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

Case Management (2)

Case Finding for Patient Education Activities

The Isle of Wight is piloting an innovative project that is directed at people with certain LTCs who are at an earlier stage of their disease and sit lower down in the risk pyramid

Their ‘Café Clinic’ project is targeting patients in the moderate to high (rather than the very high) risk categories who have two or more long term conditions

The objective of the project is to introduce these people to members of the multi-disciplinary team and members of the voluntary sector who can support them in the management of their disease

It is hoped that earlier intervention in the management of these patients and education of them and their carers will help maintain health status and reduce unnecessary emergency admissions

The ACG system has been used to identify cohorts of people to attend these clinics. Feedback after the first clinics was that all of the patients the tool had identified were suitable for this new type of service

The ACG system will now being used routinely to identify suitable individuals for the service as it is rolled out to other localities

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South Central Primary Care Trust Alliance

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Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

Case Management (3)

Supporting End of Life Care

Dr Richard Coppin , a GP in Hampshire who is leading on the End of Life workstream asked if the outputs from the ACG system could support case finding for patients approaching the end of their life

The current practice for identifying patients in the last year of their life is a combination of the use indicators such as patients with advanced cardiovascular or pulmonary disease plus input from GPs based on their knowledge of patients who fit the criteria

We investigated the findings of the work that Austin et al did in 2011 – “Two Points-Based Scoring Systems for the Johns Hopkinson Aggregated Diagnosis Groups to Predict Mortality in a General Adult Population Cohort in Ontario, Canada”

We have applied the mortality risk score (MRS) algorithm to the ACG outputs for Dr Coppin’s practice population to generate an MRS score for each adult in the population

We are now prospectively monitoring the actual outcomes of the patients generated in December using the ACG data so that we can undertake a PPV analysis later this year

In the meantime the MRS list is proving to be a useful adjunct to their existing processes for identify patients in the final year of their life

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South Central Primary Care Trust Alliance

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Resource Management

• Examples of the use of information to support the resource management agenda include:

Risk Stratification

Resource Management

Case Management

ACGs

Disease Profiling

• Identify highest cost patients and reviewing them

• IOW are using the tool to identifying patients on multiple drugs and passing this information to the Medicines management Team for review and where appropriate, a medicines review with a pharmacist

• Identifying high users of secondary care services but who have none or little interaction with their GP practice

• Just starting to use the tool to evaluate impact of community based services on those with similar disease patterns who access these services and those that have never been referred

Very High High Moderate Low Healthy Non Users

• But …… one of the biggest opportunities comes from being able to create a balanced scorecard of indicators such as referral rates, pharmacy costs, emergency admissions etc and adjust this for case mix differences between different populations

• And … we are following the work in Sweden where they have used ACGs to develop a case-mix adjusted resource allocation formula based on the needs and morbidity burden of each individual in a population

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South Central Primary Care Trust Alliance

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Key Learning

The system is not perfect but the information and intelligence produced by the ACG System is more than good enough to inform commissioning and case management activities

The ACG predictive model has it’s limitations (as do all predictive models) but through the use of multiple markers and filtering criteria, primary care staff and GPs are finding suitable patients for their services. It is also only ever an adjunct to existing processes and there still needs to be a clinical triage process and other methods of referring patients to case managers/community matrons

It’s not just about the use of the tool to support case management – its about exploiting the other functionality that the tool provides to support commissioning decisions

We need to focus on more than just the top 1% (or even 5%) – information about people lower down the risk pyramid will have an increasingly important role as more services are established to maintain/improve the heath of people with LTCs

Benefits realisation requires a community of interest. The larger the community of interest and the more clinical input, the greater the benefits that can be realised

At the end of the day, the information from the ACG System or any risk stratification/predictive modelling tool is just information – it’s what organisations do with it that is making the difference

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South Central Primary Care Trust Alliance

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Next Steps

The next steps in our programme include:

• The continued roll out of the ACG tool across the region

• Working with PCTs and GPs in South Central to exploit the full functionality of the ACG system and the use of the information to support effective use of resources will become increasingly important

• Enhancing the reporting functionality and upgrading to the latest version of the ACG System that provides new functionality and additional predictive models

• Sharing learning within the NHS with other users of the ACG system through the recently established National ACG User Group

We want to be able to provide some more empirical evidence that the use of the ACG system enhances the identification of patients who are most likely to benefit from Community Matron care and an integrated care team approach

The work of prospectively monitoring of the effectiveness of the mortality model will continue and hopefully we will be able to discuss the results at the JHU London Symposium in October

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South Central Primary Care Trust Alliance

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Contact Details

Further information about the risk stratification and predictive modelling programme in South Central can be obtained from: