1. Long Term Conditions with United Health Europe Jean Robinson Nottingham HIS

2. Background Several pilot projects across Nottingham Rushcliffe LTC B&H COPD Gedling Action Team (GAT) Various City projects – May Scheme, Intermediate Care etc SHA keen for Nottingham to implement LTC

3. LDP Emergency Admissions Readmissions Community Matrons

4. UHE January / Feb 2005 presentations to Nottingham Health Community June/July 2005 – signed up by TSHA Nottingham City – lead PCT Lead site for RISC and HealthNumerics

5.  Demographics  Clinical Care  Pharmacy  (Lab Results) Clinical Risk Markers Service Based Risk Markers Demographic Markers Patient Clinical Risk Profiles Weighting of Profile to Compute Risk Complete Patient Risk Profile Episode of Care Based Disease Prevalence Co-morbidities Complications High Acuity Events - Moderate/Lower Risk Markers - Rx Markers - Lab Markers Age Gender Geography Array Markers for each Patient to Create a Clinical Risk Profile Apply Weights Measuring Contribution of each Marker to Overall Risk Combine Profile and Risk Results to Complete Patient Profile Analysis Outputs RISC Model: to predict high risk patients

6. The process Caldicott approval Extract the data (Pop and Acute to start with) Anonymise NHSNumber Send the data to UHE Data returned Print reports for community matrons HealthNumerics Installation and training

7. The data Registered list Inpatient activity – 3 years Outpatient activity – 3 years A&E activity – 3 years Reference data

8. The data MS Access files, one per PCT Very specific file formats – as ClearNet Reference files GPPractice codes, Trust Codes, LSOAs and wards

9. Anonymise nhsnumber Various methods discussed with UHE Created Master patient index and new autoID number for each nhsnumber Easy – but master index needs to be kept secure and up to date Not scalable – if PCTs merge…

10. Data sent to UHE UHE process the data Attach a RISC score to each patient RISC is designed to estimate for an individual person their future risk of health care service usage RISC provides a report which outlines factors that drive the risk score

11. Data Returned - RISC 4 databases (one per PCT) Replace AutoID with NHS Number Pre written reports 1. List of patients in RISC order 2. Individual patient profiles

12. Patient Lists

13. Patient Profile

14. Health Numerics Analysis tool developed by UHE Uses Population data (Registered list, Census data and activity data) Provides aggregate reports Standard reports User reports – based on selecting criteria

15. Health Numerics Allows analysis by SOA, LSOA and ward GP Practice Other pre-specified geographies (localities etc) IMD quintiles

16. 5 views Population Census variables Age /sex breakdown Commissioning Inpatient, outpatient & A&E activity PbR, tariff costs Primary care services Activity by practice - PbC Care management – primary care data Patient Choice – out of area activity

17. UHE experience Very focussed on deadlines and getting things done Supportive but demanding Data preparation time consuming Reports can be time consuming No clear market for HN Future costs could be considerable