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Identifying and Selecting Patients for Integrated Care Interventions in NSW: Unpacking Risk Stratification


Erin K Lilley

NSW Ministry of Health, AU
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The number of people in Australia living with complex and chronic conditions is increasing. As a result, patients are experiencing more hospitalisations, with the associated additional costs to the healthcare system in NSW.

If people with, or at risk of developing, chronic conditions can be identified early and offered a health care intervention that meets their needs, it may be possible to improve their outcomes. It may also be possible to make savings for the health service through prevented complications and reduced hospital admissions.

Risk stratification is a planned process by which health care interventions are targeted to those who might benefit from them the most. It is not a solution on its own, and must be included within a broader strategy to deliver better patient outcomes.

NSW Health has invested $180M over six years in an integrated care strategy. Within the context of this strategy ‘risk stratification’ is defined as: ‘a systematic process to target, identify and select patients who are at risk of poorer health outcomes, and who are expected to benefit most from a particular intervention or suite of interventions’.

Effective targeting, identification and selection of patients can play an important role in ensuring that those who are able to receive appropriate care within a community setting actually receive their care there.

Three stages of risk stratification have been defined:

Targeting: Choose and quantify the cohort of patients at risk of poorer health outcomes (e.g. Potentially Preventable Hospitalisations) that are considered a priority for targeting with different or additional interventions.

Identification: identify individuals within the established target cohort. This is achieved through manual or automated searching of routinely collected clinical and demographic data held in electronic databases using a standardised set of risk predictors.

Selection: use a selection tool to undertake further assessment of each identified patient’s modifiable risk, and match their needs to the most appropriate integrated care interventions. This can be administered via telephone or face-to-face, and generally requires information not held in the electronic medical records (eMRs).

Drawing on a review of international literature and local experience, this presentation will also discuss key principles for implementation of risk stratification approaches, and outline a template that has been developed to support planning and implementation of risk stratification.

How to Cite: Lilley EK. Identifying and Selecting Patients for Integrated Care Interventions in NSW: Unpacking Risk Stratification. International Journal of Integrated Care. 2017;17(3):A85. DOI:
Published on 11 Jul 2017.


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