Practical Risk Stratification and Clinical Case 
Finding in the WELC Pioneer Programme
The WELC System
A snapshot of the health needs in WELC:
• Deprivation is twice as high as the national average.
• Half of ...
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
...
Qadmissions (Newham and Tower Hamlets)
• Commissioned by THPCT from Qresearch
(www.qadmissions.org)
• Modelled on a popula...
Qadmissions
• Age, Sex, Ethnicity, Postcode, Strategic health authority
• Smoking status, Alcohol status
• Diabetes (type ...
Governance
Sometimes life hits you in the head with a brick. 
Don't lose faith.
Steve Jobs
Data 
Processor 
(eg NEL 
CSU)
Data Controller 
(Acute Provider 
BH)
Data Controller 
(GP)
Data Controller 
(MH Provider –...
Fair Processing
• Template strategy produced for all partners
• Materials being packaged – NELCSU including
– Poster 
– Le...
Be really clear about each problem you are
trying to solve and why it’s important
What are we commissioning for integrated care ?
How are these scores used clinically
• Target population
– Monthly review of the data – GP led
– Enrolment of patients int...
Consent
Bethan George: WELC Care Collaborative, 30 June 2014
Bethan George: WELC Care Collaborative, 30 June 2014
Bethan George: WELC Care Collaborative, 30 June 2014
Bethan George: WELC Care Collaborative, 30 June 2014
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Bethan George: WELC Care Collaborative, 30 June 2014

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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.

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Bethan George: WELC Care Collaborative, 30 June 2014

  1. 1. Practical Risk Stratification and Clinical Case  Finding in the WELC Pioneer Programme
  2. 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
  3. 3. 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 ?
  4. 4. 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)
  5. 5. 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
  6. 6. Governance Sometimes life hits you in the head with a brick.  Don't lose faith. Steve Jobs
  7. 7. 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
  8. 8. Fair Processing • Template strategy produced for all partners • Materials being packaged – NELCSU including – Poster  – Leaflet – Animation
  9. 9. Be really clear about each problem you are trying to solve and why it’s important
  10. 10. What are we commissioning for integrated care ?
  11. 11. 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
  12. 12. Consent

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