The NSW Integrated Care team is implementing an e-enabled risk stratification process for identifying persons at risk of rehospitalisation within 15 months. This will be built into the Patient Flow Portal, a system that assists staff to improve patient flow and patient experience across our organisations.

In the NSW Health integrated care context, ‘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. This process requires a mathematical algorithm based on a range of clinical data, clinician judgement and patient participation.

It is important to recognise that risk stratification is a planned process, not a solution. On its own, it cannot deliver better patient outcomes. There are three stages of risk stratification:

  1. Targeting – choose and quantify the cohort of patients at risk of poorer health outcomes that are considered a priority for targeting with different or additional interventions.
  2. 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 standardised set of risk predictors.
  3. 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. election – 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.
Page Updated: Wednesday 31 October 2018
Contact page owner: System Performance Support