1. South Central
Primary Care Trust Alliance
________________________________________________________________________________________________
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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2. South Central
Objectives of This Session Primary Care Trust Alliance
________________________________________________________________________________________________
 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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3. South Central
Background Primary Care Trust Alliance
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 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. 3

4. High Level Overview of the Infrastructure that Supports South Central
Access to Risk Stratification Information Primary Care Trust Alliance
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Series of IG related processes that comply with all
current regulations and guidance
Informing Automated
patients extraction Access to a
and of primary Series of
managing care data Standard
from GP Secure Environment Reports
potential
Practice
opt out System
Secondary Data Data Allocation Direct Web
care combination, repository of User
ACG Based Access
activity mapping & Training
Grouper & reporting Names & to Tool via
data from prep for tool Passwords Desktop PC
SUS upload
Access to
Reference Data into and out of server via N3 connection ‘Hypercubes’
Data for bespoke,
multi-
dimensional
analysis
 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 4
information

5. South Central
Progress Over the Last 21 Months Primary Care Trust Alliance
________________________________________________________________________________________________
 Over 240 practices across 20 CCGs
and all nine PCTs now have access
Status of Roll Out Programme – to risk stratification and predictive
No. of GP Practices by PCT 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 5

6. The Four Key Areas that South Central
ACG Outputs Are Supporting Primary Care Trust Alliance
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Risk Stratification Disease Profiling
•Stratification of patients into iso- •Allocates patients to one or more of 264
resource groups disease categories to facilitate disease
•Provides understanding the case mix profiling
of a practice, CCG and PCT population •Profiling can be done at practice, locality
•Helping to identify gaps between or PCT level
service provision and health need •Public Health very interested in this
•Supporting commissioning decisions aspect as it can support JSNA
ACGs
Resource Management Case Management
•Understand differences in case mix •Flags likely high risk, high cost
between different practices patients
•Combine with other indicators such as •Has other markers such as ‘hospital
referral rates to create ‘balanced dominant count’ that allow targeting
scorecard’ based on disease burden of patients
•Use of pharmacy outputs to support •This is the functionality being most
medicines management agenda used at the moment
•Benchmarking between practices
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7. South Central
Risk Stratification (1) Primary Care Trust Alliance
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• 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
• 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
Risk Disease
Stratification Profiling
ACGs
Resource Case
Management Managemen
t
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8. South Central
Risk Stratification (2) Primary Care Trust Alliance
________________________________________________________________________________________________
• 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
Very High High Moderate Low Healthy Non Users
• 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
Risk Disease
Stratification Profiling
ACGs
Resource Case
Management Managemen
t 8

9. South Central
Disease Profiling (1) Primary Care Trust Alliance
________________________________________________________________________________________________
• 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
Risk Disease
Stratification Profiling
ACGs
Resource Case
Management Management
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10. South Central
Risk & Disease Profiling in Combination Primary Care Trust Alliance
________________________________________________________________________________________________
• 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
• 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
Stratification Profiling
ACGs
Resource Case
Management Management
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11. Case Management (1) South Central
Primary Care Trust Alliance
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Risk Disease
Stratification
ACGs
Profiling
Case Finding for Community Matrons and
Resource
Management
Case
Management
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 11

12. South Central
Case Management (2) Primary Care Trust Alliance
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Risk Stratification Disease
Profiling
Resource
ACGs
Case
Case Finding for Patient Education Activities
Management Management
 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 12

13. South Central
Case Management (3) Primary Care Trust Alliance
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Risk Disease
Stratification Profiling
ACGs
Supporting End of Life Care
Resource Case
Management Management
 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
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identify patients in the final year of their life

14. South Central
Resource Management Primary Care Trust Alliance
________________________________________________________________________________________________
• Examples of the use of information to support the resource Risk
Stratification
Disease
Profiling
management agenda include: ACGs
Resource Case
Management Management
• 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
• 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
Very High High Moderate Low Healthy Non Users 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 14

15. South Central
Key Learning Primary Care Trust Alliance
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 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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16. South Central
Next Steps Primary Care Trust Alliance
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 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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17. 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:
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