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Risk Stratification in NSW

Risk stratification approaches support a focus on organising care to meet the needs of targeted patients and their carers, rather than organising services around provider structures. Early identification and selection of people at risk of poorer patient health outcomes will enable the provision of appropriate integrated care interventions and mitigation strategies.

Integrated care delivery benefits anyone with healthcare needs; however, it is particularly important for people with complex and chronic conditions, helping them to better manage and maintain their own health and independence, and stay out of hospital for as long as possible.

Risk stratification has an important role in ensuring that patients who can received appropriate care within the community setting receive their care there, leading to a reduction in avoidable hospitalisations and the frequency of unnecessary hospital admission and emergency department attendances.

Key definitions

In the NSW Health Integrated Care context ‘risk stratification’ is defined as: a systematic process to target, identify an 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.

There are three stages of risk stratification.

  • 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 target cohort. This is achieved through manual or automated searching of routinely collected clinical and demographic data held in electronic databases using a strandardised 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 eMR .

Further guidance on the NSW approach to risk stratification can be found in the ‘Patient identification and selection handbook’.

Risk Stratification Program

Investment in risk stratification resources to support Local Health Districts/Specialty Hospital Networks was identified as a system enabler in the NSW Health Integrated Care Strategy. The ACI is responsible for managing this component of the Strategy.

The program aims to ‘develop a NSW approach for risk stratification and patient selection to guide the identification of people who are at risk(s) of poorer health outcome(s), and enable targeted delivery of integrated care to those who will maximally benefit’.

The NSW approach will include a range of tools, processes and resources that can be applied by local health districts and healthcare providers to identify people at risk of illness or chronic disease that can be followed-up by early, targeted intervention.

Patient Identification and Selection Handbook

Drawing on Australian and international evidence, the Patient identification and selection handbook has been developed to provide practical and evidence-based guidance to health services establishing or expanding their risk stratification approaches to patient identification and selection.

The handbook is primarily for use by local health districts, specialty health networks, primary health networks and other health, community and social care providers involved in  identifying and delivering care to patients who are at risk of poorer health outcomes and likely to benefit from additional care interventions.

In addition, a decision support tool has been developed to summarise a range of patient identification and selection tools, and guide selection of tools for local health districts and their partners.

Discussion Paper

In late 2014, the ACI undertook an initial literature review and consultations with key stakeholders to inform the development of a discussion paper (released Dec 2014): Risk Stratification: A discussion paper for NSW Health's approach to Risk Stratification. The paper was intended to stimulate discussion about the approach for risk stratification and the next steps for this stream of the NSW Integrated Care Program.

Thirty responses were received and analysed, and the information is being used to inform the next steps in the Risk Stratification Program. The key themes and issues raised in the responses are summarised in this report.

Program Implementation

Five work streams are currently underway or planned that will test different approaches for risk stratification / patient selection over the next 6 – 18 months:

  1. The three Demonstrator sites are developing and testing local risk stratification approaches as part of the Integrated Care Program.
  2. Innovator sites are also developing patient selection approaches as part of their local Integrated Care programs.
  3. Develop patient selection/risk stratification methodology(ies) as part of the redesign of the Chronic Disease Management Program.
  4. Linking Primary Health Care and NSW Health data project(s).
  5. Develop resources and support knowledge exchange between local sites.

In addition, an iterative monitoring and evaluation approach is being developed to ensure that learnings are identified early, adjustments are made as required, and value of the program is able to be measured.

The ACI will work closely with the Ministry of Health and E-health to support the delivery of these work streams.


Evidence Reviews

Two Evidence Check rapid reviews have been commissioned through the Sax Institute to support the Risk Stratification Program:

In addition, the Australian Primary Health Care Research and information Service (PHCRIS) published a Policy Issue review in May 2015:

Sharing Local Activities


Three Integrated Care ‘Demonstrators’ – led by Western Sydney, Central Coast and Western NSW Local Health Districts (LHDs) – have been allocated funding from the NSW Government’s commitment of $120 million over four years to progress system-wide approaches for integrating care at a local level.

More information about their Integrated Care Programs can be found here.


Part of the $120 million NSW Government investment in new, innovative models of care was allocated to a Planning and Innovation Fund to support discrete and innovative integrated care initiatives run by Local Health Districts (LHDs) and Specialty Health Networks with their partner organisations.

More information about their Integrated Care Programs can be found here.

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