As our population ages and the prevalence of long term conditions increases, the case for managing our multi-morbid population in a different and more holistic way emerges. As a result, the need for information that describes our populations and the individual people in it has never been greater.
There are a number of policy areas that promote the identification and management of high risk patients, with a belief that those most at risk of emergency admission are the highest cost patients, that they tend to have particular high impact diseases like COPD and heart failure, are elderly and are frail. While this is the case with some of the high risk and high cost individuals, this is not true of all of them.
In fact the top 2% of people most at risk of an emergency admission are a very heterogeneous group. There are several discrete types of patients whose care needs are different and each needs a different type of intervention to prevent avoidable emergency admissions. There is also an increasing recognition that many of these cohorts of patients cannot have their needs met by a traditional community matron type service.
This case study provides an overview of a series of analyses undertaken in Slough Clinical Commissioning Group using data from the Johns Hopkins Adjusted Clinical Groups® (ACG®) System to improve the CCG’s understanding of its population, to better understand the factors that drive cost and create risk, and to illustrate the relationship between population profiling techniques and case finding activities.