whole systems integrated care (wsic) dashboards: risk ... · 30/05/2019 0.2 rachel meadows added...
TRANSCRIPT
Whole Systems Integrated Care
(WSIC) Dashboards: Risk
Segmentation Radar
User Guide – V2.0
Page|2 Page|2
North West London Collaboration of
Clinical Commissioning Groups
Version History
Date Version Author Notes
28/05/2019 0.1 Rachel Meadows First Draft
30/05/2019 0.2 Rachel Meadows Added coding
03/06/2019 0.3 Kavitha Saravanakumar Added to introduction and the methodology
13/06/2019 0.4 Kavitha Saravanakumar Included text to Methodology section based on James H’s feedback
17/06/2019 1.0 Rachel Meadows Reviewed and published
11/09/2019 2.0 Rachel Meadows Added information about Previous Risk Segment
Page|3 Page|3
North West London Collaboration of
Clinical Commissioning Groups
Contents Version History .................................................................................................................................................................. 2
Section 1: Introduction to the Risk Segmentation Radar ................................................................................................. 6
What is the Risk Segmentation Radar? ............................................................................................................................. 7
Why was the Risk Segmentation Radar developed? ........................................................................................................ 7
How does the Risk Segmentation Radar work? ................................................................................................................ 8
How might the Risk Segmentation Radar improve health and change practice? ............................................................ 9
How can the Risk Segmentation Radar be improved in the future? .............................................................................. 10
Section 2: Methodology .................................................................................................................................................. 11
Risk Segmentation Radar | Reason for developing the model ....................................................................................... 12
Risk Segmentation Radar | How the model was developed .......................................................................................... 15
Risk Segmentation Radar | Risk Segments ..................................................................................................................... 17
Risk Segmentation Radar | Limitations........................................................................................................................... 18
Risk Segmentation Radar | Further Reading and Links .................................................................................................. 18
Section 3: Data ................................................................................................................................................................ 19
Risk Segmentation Radar | Data Provenance ................................................................................................................. 20
Page|4 Page|4
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Data Frequency ................................................................................................................... 20
Section 4: Step by Step Guide ......................................................................................................................................... 21
Risk Segmentation Radar | Homepage ........................................................................................................................... 22
Risk Segmentation Radar | How to use the radar .......................................................................................................... 23
Section 5: Calculation Definitions ................................................................................................................................... 27
Risk Segmentation Radar | Previous Risk Segment ........................................................................................................ 28
Risk Segmentation Radar | A&E and UCC / walk in attendances ................................................................................... 29
Risk Segmentation Radar | GP events ............................................................................................................................ 30
Risk Segmentation Radar | Number DNAs ..................................................................................................................... 30
Risk Segmentation Radar | District Nursing ................................................................................................................... 31
Risk Segmentation Radar | No Contact with GP practice in last 18 months .................................................................. 31
Risk Segmentation Radar | Failing Key Care Processes .................................................................................................. 32
Risk Segmentation Radar | New Diagnosis ..................................................................................................................... 33
Risk Segmentation Radar | Recently Bereaved .............................................................................................................. 33
Risk Segmentation Radar | Patient Activation Measure ................................................................................................ 34
Risk Segmentation Radar | Harmful Alcohol / Substance Misuse .................................................................................. 35
Page|5 Page|5
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | BMI ...................................................................................................................................... 37
Risk Segmentation Radar | Smoking Status .................................................................................................................... 37
Risk Segmentation Radar | Polypharmacy...................................................................................................................... 38
Risk Segmentation Radar | Housebound ........................................................................................................................ 39
Risk Segmentation Radar | Is a Carer ............................................................................................................................. 39
Risk Segmentation Radar | Living Alone Status .............................................................................................................. 39
Risk Segmentation Radar | Deprivation Grouping.......................................................................................................... 40
Risk Segmentation Radar | Sorting ................................................................................................................................. 42
Risk Segmentation Radar | Print ..................................................................................................................................... 43
Page|6 Page|6
North West London Collaboration of
Clinical Commissioning Groups
Section 1: Introduction to the Risk
Segmentation Radar
Page|7 Page|7
North West London Collaboration of
Clinical Commissioning Groups
What is the Risk Segmentation Radar?
The Risk Segmentation Radar is a WSIC dashboard which allows GP Practices to understand the level of risk and
complexity of their patients. It allows the user to order, group and filter patients on their list according to a range of
criteria - some relating to a level of risk and some to levels of activity they have in different service settings. Outlying
scores are all highlighted on the radar in red to aid interpretation of this patient-level data.
Why was the Risk Segmentation Radar developed?
Northwest London CCGs was successful in securing money from NHS England as part of the ‘GP at Scale’ project to
develop a tool which focused on a ‘population health management’ approach.
Population health management means taking a proactive approach to managing the health and well-being of a
population. It involves segmenting the population into groups of people with similar needs to enable targeted
interventions for both those population cohorts and those within them.
The tool is designed to support the development of Primary Care Networks, so they can take a population-based and
network-based approach to improving health.
Page|8 Page|8
North West London Collaboration of
Clinical Commissioning Groups
How does the Risk Segmentation Radar work?
Put simply, the Risk Segmentation Radar is
a way of highlighting to GP practices the
level of risk and complexity of their
patients, in a more simple and visual way
than their GP systems currently allow.
It brings together data into WSIC from a
range of sources, so provides a more
‘joined up’ picture of risk of poor/
declining health than just GP systems
alone. It then groups patients into risk
groups according to the likely support
needs of that risk group:
The details around how this grouping was developed
and which factors included are covered in the next
section: Methodology.
Risk group Possible support needs
Specialist/ End of Life
Patients already likely to be receiving End of Life or Specialist Services and therefore probably not appropriate for case management or care planning
High Risk Very complex patients with comorbidities and/or high admission risk who may benefit from case management to co-ordinate their care more effectively
Rising Risk Patients with existing conditions who are also outliers for service use or control of their health. May be suitable for proactive care at Network or Practice level
Stable Risk Patients with existing conditions who are NOT outliers for service use or control of their health. Likely to be suitable for routine LTC management at Practice level (e.g. QOF)
Well Patients with no long-term conditions or risks who may be most suited to transactional care (e.g. routine appointments)
Page|9 Page|9
North West London Collaboration of
Clinical Commissioning Groups
These categorisations are just one of a number of indicators displayed in the radar. The radar also includes patient-
level data on aspects such as:
Outlying use of services: e.g. high GP, A&E, Non-electives, DNAs
Outliers in at least one of the existing WSIC dashboards for key clinical processes: COPD, Asthma, Diabetes,
Heart Failure, Hypertension, SMI
Risk of hospital admission (using the QAdmissions algorithm)
Lifestyle and housing/ living circumstances e.g. smoking status, deprivation and living alone
How might the Risk Segmentation Radar improve health and change practice?
The radar may be useful in a number of scenarios:
Allowing Practices or Networks to have a greater understanding of their patients, including those who they
don’t see so often.
Identifying cohorts of patients for Practice or Network-based interventions e.g. case management for high
risk patients, proactive care for rising risk patients and specific interventions for other scenarios e.g. social
prescribing initiatives
Monitoring the success of managing Rising Risk patients – does their activity return to normal over time?
More detail on how to identify cohorts of patients can be found in ‘How to use the Radar’ below.
Page|10 Page|10
North West London Collaboration of
Clinical Commissioning Groups
How can the Risk Segmentation Radar be improved in the future?
The Radar has been tested with a number of GP Practices prior to release. However, there are likely to be a number
of significant improvements to be made in future releases on the basis of feedback from users.
If you have any feedback, positive or negative, please
email this to inform future releases:
Page|11 Page|11
North West London Collaboration of
Clinical Commissioning Groups
Section 2: Methodology
Page|12 Page|12
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Reason for developing the model
The development of the tool was designed to support the emergence of Primary Care at Scale – a new model of
working for General Practice (mentioned in the General Practice Forward View, April 16). In this model, GP practices
are expected to work at a Network level in some instances in order to gain efficiencies and improve quality. The
image on the following page details the new approach to working within an Integrated Care System (ICS). The
approach of working ‘at scale’ was supported by a proposed segmentation model in General Practice, where
“Segmentation involves splitting up the population receiving general practice into different groups and
arranging different services for them.”
Divided We Fall. Getting the best out of general practice, Rebecca Rosen, Nuffield Trust Feb 18.
https://www.nuffieldtrust.org.uk/files/2018-02/nt-divided-we-fall-gp-web.pdf
Based on these approaches, NW London developed a conceptual model on how patients in differing risk segments
could be supported at different organisational levels to meet their needs. As needs changed, patients would move to
the appropriate level (see image).
The tool was initially designed to identify ‘rising risk’ patients who could be supported with proactive care at a
Network level.
Page|13 Page|13
North West London Collaboration of
Clinical Commissioning Groups
Page|14 Page|14
North West London Collaboration of
Clinical Commissioning Groups
Most
complex
Rising risk
Moderately
Complex
Stable risk
Well Core general practice. Coordination and planning of holistic accessible care 8 – 8 7 days a week
Primary Care Networks teams of practices –assess population needs and design integrated care services with community health and social care providers
Multidisciplinary Workforce arranged in teams with case management across health and social care.
75-80% of patients
2-3% of patients
15-20% of patients
PATIENTS SETTINGS
‘Rising risk’
‘Highest risk’
‘Well’
Page|15 Page|15
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | How the model was developed
Two workshops were initially held with key stakeholders to construct an approach which could use data to identify
patients considered as ‘rising risk’. Rising risk was understood to be ‘showing signs of a short term or recent
deterioration in health, which may lead to a longer term decline if not managed properly’.
Based on stakeholder discussions, the identification of ‘rising risk’ patients focused on ‘removing’ (a) well patients (b)
those who had a health condition but were managing it and (c) those patients already with poor enough health to be
eligible for (or receiving) case management. The remaining cohort could then be considered ‘rising risk’.
Risk stratification tools and multivariate analysis were discussed as approaches for identifying levels of risk.
However, a segmentation approach was favoured over risk stratification, as the purpose of the tool was much
broader than simply predicting hospital admission risk, given the focus on targeting patients to delivery settings like
Networks. Also, the evidence base around risk stratification has been mixed:
https://www.england.nhs.uk/wp-content/uploads/2015/01/nxt-steps-risk-strat-glewis.pdf
Nevertheless, the QAdmissions algorithm was incorporated into the Radar as another means of predicting risk if
required and has proven to be useful in identifying cohorts for case management pilots.
Page|16 Page|16
North West London Collaboration of
Clinical Commissioning Groups
A pragmatic approach was taken to define the risk groups, based on emerging thinking from the Nuffield Trust, NHS
England, The Health Foundation and the Bridges to Health Model (see links above and below). The logic for creating
the groups was then tested pragmatically during GP visits to test for Rising Risk ‘false positives’ and ‘false negatives’
and several changes were made as a result. In particular, an additional grouping of ‘Specialist/ End of Life’ was
created to separate out patients who would not be appropriate for case management due to the specialist nature of
their needs.
Feedback from stakeholders centred around outlying service use as being the main indicator of ‘rising risk’ in their
clinical experience, with particular reference to high A&E use or a lack of engagement through DNAs. This was built
into the model to separate out rising from stable risk. For a patient to be rising risk, they must have two or more
outlier ‘deficits’ to count.
Cut-offs to define ‘outlying’ activity were calculated pragmatically to identify an ‘acceptable’ volume of rising risk
patients for GP Practices to manage: top 3-4% for GP events (100+ events); top 1-2% for A&E attendances (3+ A&E
attendances); top 0.5-1.0% for NEL admissions (4+ NEL admissions) .
Page|17 Page|17
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Risk Segments
Specialist/ End of Life High Risk Rising Risk Stable Risk Well Patients already likely to be receiving End of Life or Specialist Services and therefore probably not appropriate for case management or care planning
Very complex patients with comorbidities and/or high admission risk who may benefit from case management to co-ordinate their care more effectively
Patients with existing conditions who are also outliers for service use or control of their health. May be suitable for proactive care at Network or Practice level
Patients with existing conditions who are NOT outliers for service use or control of their health. Likely to be suitable for routine LTC management at Practice level (e.g. QOF)
Patients with no long-term conditions or risks who may be most suited to transactional care (e.g. routine appointments)
Any of the following:
On Palliative Register
Renal dialysis/ Chronic Kidney Disease Level 5 patient
Cancer treatment (last 18 months)
Known to Community Matron (last 6 months)
Living in Residential/ Nursing home (aged 65+)
Not in Specialist/ End of Life group, but with any of the following:
Severe eFI
2% most likely to be admitted (QAdmissions)
4+ Non-elective admissions (last 12 months)
Known to District Nursing (last 6 months)
Housebound and receiving community services
Not in Specialist/ End of Life or High Risk groups Meeting the requirements for inclusion into the Stable Risk group But flagged in two or more of the following ‘Rising Risk’ categories:
3+ A&E attendances (last 6
months) 100+ GP events (last 6
months) 3+ DNAs (GP, Outpatient,
Community in last 6 months) Failing Key clinical
‘markers’ (Heart Failure,
COPD, Hypertension, Asthma, Diabetes, SMI)
In an at-risk category (e.g.
Dementia, falls risk, new LTC diagnosis, recent bereavement, 75+ and carer,75+ and living alone, PAM low engagement)
Not in Specialist/ End of Life, High Risk, or Rising Risk groups Meeting the requirements for inclusion into the Stable Risk group – any of the following:
Moderate eFI
On 1+ QOF disease registers (Exceptions: obesity,
smoking, hypertension, hypothyroidism, asthma non-inhaler, depression)
Non-Diabetic Hyperglycaemia or CVD risk (QRisk 20+)
Substance misuse/ alcohol dependence
Morbid obesity (BMI 40+)
20% most likely to be admitted (QAdmissions)
Not in any of the other Risk groups
0.7% of total adult population* 2.9% of total adult population* 0.6% of total adult population* 19% of total adult population* 77% of total adult population*
* Estimated percentages based on research
Page|18 Page|18
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Limitations
A pragmatic approach has been taken to form the definition of the risk groups, which has been backed up by
clinical knowledge and the available evidence base. This will need to be tested in terms of accuracy and
practicality in reality. There may prove to be better ways to define these groups in the future.
There are instances where data is inaccurate, missing, or not in WSIC, which will impact on the quality of
categorisation.
GP activity is currently measured as ‘GP events’, which includes Read coded activity rather than just
consultations. This is because consultation data is not collected. Some patients may have high activity for
reasons not related to consultations e.g. onward referrals etc.
Risk Segmentation Radar | Further Reading and Links
https://www.health.org.uk/improvement-projects/personalising-care-for-patient-sub-groups-in-general-practice-
segmenting-within
https://www.health.org.uk/chart/chart-characteristics-of-frequent-attenders-at-general-practice
https://outcomesbasedhealthcare.com/bridges-to-health-segmentation-model/
https://www.nuffieldtrust.org.uk/files/2017-01/supporting-patients-with-costly-complex-needs-web-final.pdf
Page|19 Page|19
North West London Collaboration of
Clinical Commissioning Groups
Section 3: Data
Page|20 Page|20
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Data Provenance
To find out what data the data is up to use the ‘i’ button available at the top right of the radar
Risk Segmentation Radar | Data Frequency
Data Type Frequency of update Data Availability
Acute data Monthly Data available from April 2015 onwards
Primary care data Fortnightly
Data available for all NWL patients
from the time of their registration
with a practice within North West
London region
Mental health data Monthly Data available from April 2013 onwards
Community data Monthly Data available from April 2013 onwards
Social care data Monthly Data available from April 2015 onwards
Page|21 Page|21
North West London Collaboration of
Clinical Commissioning Groups
Section 4: Step by Step Guide
Page|22 Page|22
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Homepage
You can access the Risk Segmentation Radar from the Homepage. Please refer to the ‘How to Use’ section, which
explains some of the functionality of the radar.
‘Choose a Tool’ You can access the tool through - Patient Selection - Risk Segmentation
Radar
Page|23 Page|23
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | How to use the radar
The Risk Segmentation Radar displays a list of all your patients except those categorised as falling into the ‘Well’ group. It will therefore include all patients classified as ‘Specialist/End of Life’, ‘High Risk’, ‘Rising Risk’ and ‘Stable Risk’.
The default order of patients when you enter the radar is by likelihood of emergency hospital admission*, from the most likely to the least likely.
The purpose of the Radar is:
To be able to order, group or filter these patients according to the criteria you require.
To use the supporting information provided about each patient in your selection to assess their appropriateness for your criteria before you proceed. The columns providing this information mostly use colour coding to identify whether the patient is an outlier on this indicator.
* QAdmissions is a nationally used algorithm which uses GP data to predict risk of emergency admission to hospital. Please see the website for the clinical categories included https://qadmissions.org/index.php
Page|24 Page|24
North West London Collaboration of
Clinical Commissioning Groups
You could use the Radar to identify the following:
Patients most at risk of admission – for a local case management scheme
Select ‘High Risk’. Filter out ‘Specialist/ End of Life’ as these may not be clinically appropriate.
Choose ‘Older people with 1+LTC’ from WSIC patient segment description.
Sort data by QAdmissions – risk of admission for a list of most likely patients
Review patients’ non-elective activity over the last year in the service use column.
Patients who are the biggest user of GP time to offer non-medical interventions
Sort by count of GP events – high to low.
Filter by WSIC groups that you are interested in e.g. adults with severe & enduring mental illness.
Select most relevant risk group e.g. rule out ‘Specialist/ End of Life’ and ‘High Risk’.
Review patients’ deprivation status in the ‘Housing/ living’ column to identify patients who may have challenging social circumstances.
‘Rising Risk’ patients who may benefit from care coordination at a network level Select ‘Rising Risk’.
Sort data by QAdmissions – risk of admission for a list of most ‘risky’ patients.
Review reasons why patients have been flagged as ‘rising risk’ from the supporting information (red flags) to establish appropriateness for intervention e.g. showing high service A&E use or failing a key clinical ‘marker’.
Page|25 Page|25
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | How to use the radar
The Risk Segmentation Radar displays traffic lights indicating if the item is a Red, Amber or Green Flag.
Notes on usage A missing traffic light
indicates that no data is available for the indicator
Hover over traffic lights to see when an item was last recorded and the most recent result
Total number of patients on list
Number of patients in view
Hover over points on the graph to show the date and value of the reading
Page|26 Page|26
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | How to use the radar
Notes on usage
Filter patients shown by Risk Segment
Option to sort patient list
Click on a traffic light to view patient Activity summary
Page|27 Page|27
North West London Collaboration of
Clinical Commissioning Groups
Section 5: Calculation Definitions
Page|28 Page|28
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Previous Risk Segment
Previous Segment
Key Segment
1 2 3 4 5
1 Well
New
Seg
men
t 1 =
2 Stable Risk
2 =
3 Rising Risk
3 =
4 High Risk
4 =
5 Specialist/End of Life
5 =
Risk Segmentation Radar | QAdmissions
A risk algorithm to estimate the risk of emergency hospital admission for patients aged 18–100 years in primary care. The QAdmissions algorithm incorporates 30 variables, including sociodemographic variables, lifestyle, morbidity, medication and laboratory results such as anaemia and abnormal liver function tests.
Top 5% Probability of Admission Red
Top 5-20% Probability of Admission Amber
Page|29 Page|29
North West London Collaboration of
Clinical Commissioning Groups
Lowest 80% Probability of Admission Green
Risk Segmentation Radar | A&E and UCC / walk in attendances
Three or more A&E attendances in the last 6 months Red
One or two A&E attendances in the last 6 months Amber
No A&E attendances in the last 6 months Green
Page|30 Page|30
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Non Elective Admissions Four or more non-elective admissions in the last 12 months Red
One or three non-elective admissions in the last 12 months Amber
No non-elective admissions in the last 12 months - Blank
Risk Segmentation Radar | GP events
The number of GP Events in the last 6 months
100 + Red
25-99 Amber
Less than 25 - Blank
Risk Segmentation Radar | Number DNAs
Three or more DNAs in last 6 months Red
One or two DNAs in last 6 months Amber
No DNAs in last 6 months – Blank
Out Patient DNA codes 3 and 7
Page|31 Page|31
North West London Collaboration of
Clinical Commissioning Groups
GP READ codes for DNA
9Oe3., 9NiZ., 9NiY., 9NiX., 9NiW., 9NiV., 9NiS., 9NiR., 9NiQ1, 9NiQ0, 9NiQ., 9NiP., 9NiN., 9NiM., 9NiL., 9NiK., 9NiJ., 9NiH.,
9NiG., 9NiF., 9NiE., 9NiD., 9Nid., 9Nic0, 9NiC., 9Nic., 9NiB., 9NiA., 9Nia., 9Ni9., 9Ni8., 9Ni7., 9Ni6., 9Ni5., 9Ni4., 9Ni3., 9Ni2.,
9OWA., 9Ni0., 9N4z6, 9N4z5, 9N4z4, 9N4z3, 9N4z2, 9N4z1, 9N4z., 9N4y., 9N4x., 9N4w., 9N4v., 9N4u., 9N4T., 9N4t., 9N4s.,
9N4r., 9N4q0, 9N4q., 9N4p., 9N4N., 9N4n., 9N4M., 9N4L., 9N4K., 9N4j., 9N4g., 9N44., 9ki0., 9kh2., 9HB7., 9Nip., 9Nio., 9Nin.,
9Nil., 9Nik., 9Nij., 9Nii., 9Nih., 9Nig., 9Nif., 9Nie., 9N4z8, 9N4z7, 9N4q4, 9N4q3, 9N4q2, 9N4q1, 9N4N1, 9N4N0, 9NzF.
Risk Segmentation Radar | District Nursing
If the patient has been seen by a district nursing team in the last 6 months
Including – 24 hour Nursing; 25 Hour Nursing; Adult Nursing; District Nursing; Community Nursing; District
Nursing(H&F, K&C, W); Night Nursing; Night Nursing (K&C)
If seen by District Nursing in the last 12 months Red
If not seen by District nursing in last 12 months – Blank
Risk Segmentation Radar | No Contact with GP practice in last 18 months
Not in contact with Practice within Last 18 Months Red
In contact with Practice within Last 18 Months – Blank
Page|32 Page|32
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Failing Key Care Processes
More than One Failing Key Care Processes Red
One Failing Key Care Processes Amber
Not Failing Key Care Processes - Blank
LTC Key Care Processes Failing if
Hypertension Blood Pressure BP Systolic Over 150 and Diastolic Over 90
Heart Failure Emergency admissions HF Emergency admission
Either
More than 3 Emergency admissions (any) in last 12 months or
More than 1 Heart Failure Emergency Admission in last 12 Months
COPD Smoking COPD Exacerbations
Smoker and 2 or more COPD Exacerbations in last 12 months
SMI SMWEMBSScore READ 38Q0. QRisk READ 38B10, 38DF., 38DP
SMWEMBSScore <= 40 or QRisk >= 20
Asthma Exacerbation More than 1 Asthma Exacerbation in last 12 Months
Advance Care plan out of Date 8CME., 8CML., 8CMe., 8CMg. If last updated over 12 months ago or not updated since last A&E; UCC; MIU; Walk in centre or any NEL attendance
Dementia Care Plan out of Date 8CMG2, 8CMZ., 8CMZ0, 8CMZ1, 8CMe0 If last updated over 12 months ago or not updated since last A&E; UCC; MIU; Walk in centre or any NEL attendance
Page|33 Page|33
North West London Collaboration of
Clinical Commissioning Groups
Asthma Care plan out of date 8CMA0 If last updated over 12 months ago or not updated since last A&E; UCC; MIU; Walk in centre or any NEL attendance
Risk Segmentation Radar | New Diagnosis
Any of the below diagnoses
Asthma, Atrial Fibrillation, Cancer, CHD, CKD, COPD, CVDPP, Cytology, Dementia, Depression, Diabetes,
Epilepsy, Heart Failure, Heart Failure LVD, Hypertension, Learning Disability, Mental Health, Obesity,
Palliative Care, Smoking, Stroke, Thyroid, Osteoporosis, Peripheral Arterial Disease, Rheumatoid Arthritis
New diagnosis in last two months Red
Has existing condition diagnosed more than two months ago Amber
No data recorded - Blank
Risk Segmentation Radar | Recently Bereaved
Bereaved in last 12 months Red READ codes 13M1., 13MG., 13MH., 13MI.
No Data Recorded – Blank
Page|34 Page|34
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Patient Activation Measure
Individuals have different levels of knowledge, skills and confidence to assume responsibility for their own
health and well-being. In order to tailor support according to their needs and to increase their capability to
look after themselves more effectively, it is important to be able to measure a person’s level of activation.
The Patient Activation Measure (PAM) is a validated, commercially licenced tool. It helps to measure the
spectrum of skills, knowledge and confidence in patients and captures the extent to which people feel
engaged and confident in taking care of their condition. READ code 38Qo4
Level 1: Individuals tend to be passive and feel overwhelmed by managing their own health. They may not
understand their role in the care process.
Level 2: Individuals may lack the knowledge and confidence to manage their health.
Level 3: Individuals appear to be taking action but may still lack the confidence and skill to support their
behaviours.
Level 4: Individuals have adopted many of the behaviours needed to support their health but may not be able to
maintain them in the face of life stressors. L1 - Disengaged and overwhelmed Red
L2 - Becoming aware, but still struggling Amber
L3 - Taking action Green
L4 - Maintaining behaviours and pushing further Green
Page|35 Page|35
North West London Collaboration of
Clinical Commissioning Groups
> L4 - Data Quality issue Red
No PAM recorded – Blank
Risk Segmentation Radar | Harmful Alcohol / Substance Misuse
Harmful Alcohol User and Substance Misuser Red
Moderate Alcohol User and Substance Misuser Red
Does not drink and Substance Misuser Red
No Data recorded and Substance Misuser Red
Harmful Alcohol User and has never misused drugs Red
Harmful Alcohol User and No Substance Misuse Data recorded Red
Moderate Alcohol User and No Substance Misuse Data recorded Red
Does Not Drink and No Substance Misuse Data recorded Red
Moderate Alcohol User and has never misused drugs Green
Does Not Drink and has never misused drugs Green
No data recorded and has never misused drugs Green
No Alcohol data recorded and No Substance Misuse Data recorded – Blank
Substance Misuser
READ codes 136W., 13c5., 13c6., 13c8., 13cB., 13cF., 13cH., 13cM., 1T..., 1T0.., 1T00., 1T01., 1T02., 1T03., 1T1..,
1T10., 1T11., 1T13., 1T2.., 1T20., 1T21., 1T22., 1T23., 1T3.., 1T30., 1T31., 1T32., 1T33., 1T4..,T40., 1T41., 1T42., 1T43.,
1T5.., 1T50., 1T51., T52., 1T53., 1T6.., 1T60., 1T61., 1T63., 1T7.., 1T70., 1T71., 1T72., 1T73., 1T8.., 1T80., 1T81., 1T82.,
Page|36 Page|36
North West London Collaboration of
Clinical Commissioning Groups
1T83., 1T9.., 1T90., 1T91., 1T92., 1T93., 1TA.., 1TA0., TA1., 1TA2., 1TA3., 1TB.., 1TB3., 1TC.., 1TC0., 1TC1., 1TC2.,
1TC3., 1TD.., 1TD0., 1TD1., 1TD2., 1TD3., 1V..., 1V0.., 1V01., 1V02., 1V03., 1V04., 1V05., 1V0E., 1V2.., 1V22., 1V23.,
1V24., 1V26., 1V65., 1V66., 388k., 38C3., 677T., 67H3., 8HkF., 8Hq.., 9HC.., 9HC0., 9HC1., 9HC4., 9HC6., 9HC7., 9k1..,
9k12., 9k5.., 9k50., 9N4i., 9No5., E2594, E25z., 38P03, 9HCA., 9HCB., 9N1yJ, 9NX2., 9s..., 13cM0, 1TG.., 9HCC., 38CC.,
38CG., 8G22., 8T24., 8T25.
Has never misused drugs
READ code 1V25.
Harmful Alcohol Use
READ Codes 1365., 1366., 136a., 136c., 136K., 136P., 136Q., 136R., 136S., 136T., 136W., E01y0, E23.., E231., E23z.,
E250., E2500, Eu10., Eu101, Eu102
Moderate Alcohol Use
1362., 1363., 1364., 136d., 136L., 136N., 136O.
Does Not Drink
1361., 1367., 136F., 136G., 136H., 136I., 136J., 136M., 136Z., 2577., ZV4KC
Page|37 Page|37
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | BMI
READ code 22K..
BMI less than 15 Red - This could be an indication of data quality issues
Underweight (15-18.49) Amber
Healthy (18.5-24.99) Green
Overweight (25 – 29.99) Amber
Obese (30-39.99) Red
Morbidly Obese (40-79.99) Red
Obese: not on obesity register (30-79.99) Red
BMI over 80 Red - This could be an indication of data quality issues
BMI not recorded - Blank
Risk Segmentation Radar | Smoking Status
Smoker Red READ Codes 137o., 137Z., 137Y., 137X., 137V., 137R., 137Q., 137P., 137m., 137J., 137H., 137h., 137G.,
137f., 137e., 137d., 137c., 137b., 137a., 1376., 1375., 1374., 1373., 1372., 137..
Ex-Smoker Amber READ Codes 137T., 137S., 137O., 137N., 137l., 137K0, 137K., 137j., 137F., 137B., 137A., 1379.,
1378., 1377.
Does Not Smoke Green READ Codes 137L., 1371.
No Data Recorded – Blank
Page|38 Page|38
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Polypharmacy
10 or More GP Pharmacy Prescriptions Red
Between 5 and 9 GP Pharmacy Prescriptions Amber
Between 2 and 4 GP Pharmacy Prescriptions Amber
No data recorded - Blank
Risk Segmentation Radar | MH
Has Mental Health Condition Red
No Data Recorded – Blank
MH Conditions include
Diagnosis of Depression or Anxiety (QOF)
Or Coded personality disorder
READ Codes for Personality Disorder
Eu6y3, Eu6z., Eu6yy, Eu6y2, Eu6y1, Eu6y0, Eu6y., Eu66z, Eu66y, Eu662, Eu661, Eu660, Eu66., Eu65z, Eu65y, Eu656,
Eu655, Eu654, Eu653, Eu652, Eu651, Eu650, Eu65., Eu64z, Eu64y, Eu642, Eu641, Eu640, Eu64., Eu63z, Eu63y, Eu633,
Eu632, Eu631, Eu630, Eu63., Eu62z, Eu62y, Eu621, Eu620, Eu62., Eu61., Eu60z, Eu60y, Eu608, Eu607, Eu606, Eu605,
Eu604, Eu603, Eu602, Eu601, Eu600, Eu60., Eu6.., Eu06z, Eu06y, Eu062, Eu061, Eu060, Eu06.
Page|39 Page|39
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Housebound
Housebound READ code 13CA. and Community service used Red
Is Housebound Amber READ code 13CA.
Is no longer Housebound Green READ Code 13CW.
No data recorded - Blank
Risk Segmentation Radar | Is a Carer
Is Carer Red READ Code 918G.
Is no longer a Carer Amber READ Code 918f.
Is not a Carer Amber READ Code 918r.
No data recorded - Blank
Risk Segmentation Radar | Living Alone Status
Lives Alone Red 13F2., 13F3., 13F31, 13Fc., 13FJ., ZV603
Does Not Live Alone Green 13CW., 13IL2, 13IL3, 13IL6, 13IL7, 13IZ6, 13IZ6, 13x2., 8O84., 918f., 918r.
No data recorded - Blank
Page|40 Page|40
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Deprivation Grouping
The Index of Multiple Deprivation ranks every small area in England from 1 (most deprived area) to 32,844 (least
deprived area). It is common to describe how relatively deprived a small area is by saying whether it falls among the
most deprived 10 per cent, 20 per cent or 30 per cent of small areas in England.
7 domains of deprivation
1. Income – 22.5% 2. Employment – 22.5% 3. Education – 13.5% 4. Health – 13.5% 5. Crime – 9.3% 6. Barriers to Housing and Services – 9.3% 7. Living Environment – 9.3%
1-10% Most Deprived Red
10-20% Most Deprived Red
20-30% Most Deprived Amber
30-40% Most Deprived Amber
40-50% Most Deprived Amber
40-50% Least Deprived Green
30-40% Least Deprived Green
Page|41 Page|41
North West London Collaboration of
Clinical Commissioning Groups
20-30% Least Deprived Green
10-20% Least Deprived Green
1-10% Least Deprived Green
No data recorded - Blank
Page|42 Page|42
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Sorting
The Radar may be sorted by different criteria using the dropdown menu at the top of the screen. Where
multiple patients have the same value for the sort they are ordered by NHS number.
NHS number
Age
eFI Category
Number of Red Flags
GP events
A&E attendances
QAdmissions Score
Page|43 Page|43
North West London Collaboration of
Clinical Commissioning Groups
Risk Segmentation Radar | Print
The Radar Can be printed as a pdf document by following the steps below
1. Sort and filter the list as desired using the filters
2. Click on the Print button at the top of the Radar – this will open the print view.
3. Click on ‘Download’
Page|44 Page|44
North West London Collaboration of
Clinical Commissioning Groups
4. Choose PDF from the selection
5. Select the same options as shown below and click Generate
6. This will then be ready for you to print from the PDF
Please note: Excel data extracts are not possible from Tableau, but can be arranged with the WSIC Team. If
this is required, please contact them on the email address below.
North West London Collaboration of
Clinical Commissioning Groups
For more information, please email