1. Long Term Conditions Risk Stratification
Dr Junaid Bajwa
Conway Medical Centre, Greenwich

2. About me GP Principal, Greenwich RCGP Clinical Commissioning Champion
Associate in Public Health, NHS Greenwich
Medicine’s Management Lead NHS Greenwich
GP Appraiser NHS SEL
Chair Greenwich LMC
Education Lead GPCC
Prepare to Lead alumni, NHS London 2

3. Multimorbidity: LTC
The majority of >65s have 2+conditions, & the majority of >75s have 3+ conditions
More people have 2 or more conditions than only have 1

4. Most people with any long term condition have multiple conditions in Scotland

5. The working lunch….. 16 face to face 10 minute appts
Monday
Tues
Weds
Thurs
Fri
0800am
0810am
0820am
0830am
0840am
0850am
0900am
0910am
0920am
0930am
0940am
0950am
1000am
1010am
1020am
1030am
1040am
1050am
1100am
1110am
1120am
1130am
1140am
1150am
1200pm
1210pm
1220pm
1230pm
1600pm
1610pm
1620pm
1630pm
1640pm
1650pm
1700pm
1710pm
1720pm
1730pm
1740pm
1750pm
1800pm
1810pm
1820pm
1830pm
1840pm
1850pm
1900pm
16 face to face 10 minute appts
Telephone encounters: 5-10
Home visits (2-3)
Referrals: 3 (am)
Review blood tests/Investigations
Post/ Fax/ ( letters per day)
Referrals: 3 (pm)
What about:
QoF/ LES/DES/ CIS/ Additional Services/ Child Protection/ GSF/ Information Governance/ CQC/ PRG/ Practice Meetings/ KPI’s/ Audit: Research/ Reviewing Prescribing/ HR issues/ LMC/ Public Health/ CCG
….( )….
Stepping outside the chaos to manage LTC holistically
Proactive, not reactive medicine 5

6. GP’s and Nurses in deprived areas struggle with LTC’s
“Demoralising”
“Exhausting”
“If you’re too caring ... you’ll crack up in a place like this. Our boundaries lie where they are because they have to at the moment”
“I feel like a wrung-out rag at the end of consultations”

7. "Commodities are fungible, goods tangible, services intangible, and experiences are memorable." (Lee)
Proactive management, not reactive 
Self Management
systematic transfer of some knowledge and power to maximise self-management and choice, where the GP acts as a navigator.
Motivating Staff and Patients
Focus on compassion, autonomy, mastery and purpose
(correspondence (personalized, targets individualized), pt experience, face/face, telephone)
How can we do the right thing, but also make the lives of those around us easier at the same time

8. Opportunities & challenges?
‘A pessimist sees the difficulty in every opportunity, … an optimist sees the opportunity in every difficulty’ Sir Winston Churchill

9. Long Term Conditions Module
Improving the experience of healthcare for those with long term conditions

11. Risk Stratification
The dilemma of "defining risk" for our patients on long-term conditions
Is it just the number of registers?
What about outside Qof: parkinsons, cirrhosis, inflammatory bowel disease….children….
Existing:
Hospital Admission Risk programme (HARP) High–impact User Manager (HUM) Patient At Risk of Re-hospitalisation (PARR) Probability of repeat admissions (Pra) tool
Looks at: Cancer/Diabetes/Heart Disease/Osteoporosis/Stroke
Heart Attack/ Heart Failure/ Pneumonia

12. What if we used what we have?
Metrics
Long Term Conditions
HbA1c
Cholesterol BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
Age >75
Being a smoker
Cancer,
Dementia,
COPD,
Parkinsons,
Asthma,
Cirrhosis,
Diabetes,
being on the GSF,
CKD 3,4,5,
Hypertension,
Inflammatory Bowel Disease,
Rh Arthritis,
Stroke/TIA,
AF,
Osteoporosis
HF,
Mental Health condition,
LD,

13. What if we used what we have?
Metrics
Long Term Conditions
HbA1c
Cholesterol BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
Being a smoker
Cancer,
Dementia,
COPD,
Parkinsons,
Asthma,
Cirrhosis,
Diabetes,
being on the GSF,
CKD 3,4,5,
Hypertension,
Inflammatory Bowel Disease,
Rh Arthritis,
Stroke/TIA,
AF,
Osteoporosis
HF,
Age >75
Mental Health condition,
LD,
(Modifiable)
(Fixed)

14. Within the metric….RAG Metrics RAG: R-2pts / A-1pt / G-0pt HbA1c
Cholesterol BP
MRC
eGFR*
BMI
Waist circ
Audit C score
PHQ9
Being Housebound
No of repeat
Age >75
Being a smoker
G ( ), A ( ); R (>8.5)
> 4:2: A: 1 pt if above this ratio
(>150/90; if DM/CKD/CHD >140/90) 1 pt if above
G: 3,A: 4, R: 5
G (CKD ); A (CKD ); R (CKD4,5 ie < 29)
A: (Obese**) R (:morbid obesity)
A: 1 pt if above norm
R: (>5)
(last recorded within 3m) R: 15-27; A: 5-14
A: 1 point
Repeat medications (>5): A 1 pt if above
A 1 pt if above 75
A 1pts

15. Managing the chaos: Proactive vs Reactive
Cumulative totals within each of the categories would then allow a 360° review of your registered population
Could you then establish a set of rules re: appointments; removing the monthly letters for each review/ reduce waste in the system; offer extended appointments with a focus on self management- improving the patient experience
Green
Amber
Red
Dr appts
(?around bday)
2/yr
3/yr
4/yr
Nurse appts
5/yr

16. MSDi LTC Module
The software will allocate a R,A,G, status to patients based on:
The number of long term conditions they have
Indicators used to define whether those conditions are optimally managed
No of visits a patient has made to the surgery over the last 12 m
Flexible: to allow for user defined thresholds and weightings to be allocated to each of the above parameters
A care plan will be generated for the patient which will include the number of appointments that a patient will have over the following 12 m which are dedicated to the optimal management of that patients conditions.
The software is practice based
At locality level anonymised data can be aggregated and accessed through a web-based portal, allowing risk to be stratified across a geography.

17. Set-up Rag Rating Criteria

18. Patient Stratification by No. LTCs

19. Patients with RAG rating reasons

20. No. Patient Interactions with in last 12 months

21. % Patients with No. Diseases by Age

22. Patients not controlled

23. PDSA: future add ons PDSA cycle
Coding: Number of hospital admissions A(2); R(>3);
Quantify length of stay in hospital
QRISK®2 calculates your risk of cardiovascular disease(R >30%) (A>20)
QDScore® algorithm calculates your risk of Type 2 diabetes.)
QoL score (would be useful to include this metric- we do not currently assess this in primary care)
Looking at social determinants of health: e.g. personal/ household income, social housing, postcode, use of carers, social isolation
“Not all that can be counted, counts. And not all that counts can be counted.” Albert Einstein

25. Personal Health Plan

26. Personal Health Plan

27. Personal Health Plan

28. Improving the Patient Experience
SDI. 12.GB SL
Date of Preparation: May 2012

29. For More Information: MSDinformatics Stand 171 in main hall
Call