Assessment, Awareness of Conditions & Disability, Occupational Therapy in Practice, OTalk

#OTalk – Using Risk Stratification to case find people with Long Term Conditions – Tues 5th Feb 8pm

Risk Stratification for Long Term Conditions 

Date:  05/02/2013   Host: @UK_James

Blog Post –  Transcript –   Post Chat Summary

Thanks to @uk_james for proposing this weeks topic and volunteering to host the discussion. Please join us for what is looking to be an interesting first of three.

This week’s #OTalk is the first of a series of three looking at how to meet the challenge of providing care and support to increasing numbers of people living with long term conditions, equal to, if not greater than the challenge of an ageing population.

In total around 70% of the total health and care spend in England (£7 out of every £10) is attributed to caring for people with long term conditions (LTCs).

We’ll be exploring the Department of Health’s recommendations to implement the Long Term Conditions model of care.  There are 3 components – which MUST all be done together at the same time:

  1. Risk stratification – predicting who is at risk of hospital admission
  2. Integrated health and social care neighbourhood care teams
  3. Self care – supporting people to understand and manage their own conditions better themselves

This week’s #OTalk is on the topic of risk stratification, which is all about how to use a predictive model to identify / case find people who are at the greatest risk of going into hospital.  Risk stratification tools (clever software) can also be used to identify the people who can be offered targeted preventative and self care support. It’s a bit like crystal ball gazing – looking ahead in time and working with people now to prevent a crisis at a later stage.  All too often, health and social care professionals work with people at or after a time of crisis, rather than preventing one in the first place.

risk strat

(from )

To read more about the current picture, including the changing needs of our ageing population why health and social care professionals need to adopt a different way of working, see the DH’s Long Term Conditions Compendium of Information at

Also the DH LTC website at:

There’s a great guide for staff, produced by Leeds health and social care organisations available.  Check out page 9 for an easy to read explanation of risk stratification:

A detailed implementation guide for a Long Term Conditions model of care has been developed by Kent health and social care organisations and can be found at:

Follow @SirJohnOldham , GP and National Clinical Lead for Quality and Productivity at the DH on Twitter.  He has been leading the LTC programme at a national level and tweets related observations.

During the #OTalk we’ll be covering:

  1. Gaining an understanding about the challenge of increasing numbers of people with multiple long term conditions
  2. Gaining an understanding of the process of risk stratification.  What is it and how to do it?
  3. Working out how identifying “at risk” people can benefit them / deliver better outcomes
  4. Thinking about implications for practice – what does this approach mean for you?

The next #OTalk in this series about LTCs on the topic of integrated health and social care teams will be Tuesday 5th March at 8pm.

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