A clinically designed stratification tool to develop a tier-based approach to delivery of care in general practice

Dickens Place Group

This project is under way, and will run until March 2020.

  • Project led by Dickens Place Group, a general practice in Chelmsford, Essex, in partnership with Co-formation Ltd, a health consultancy that supports transformation of primary care.
  • Will identify patients from the GP practice who need greater continuity and coordination of care.
  • Using a clinically designed stratification tool, the practice’s population will be segmented into three tiers, based on medical complexity and social care needs.

The ageing population and increase in the number of people living with long-term conditions has meant a significant rise in demand for GP appointments. The average person sees a GP six times a year; double the rate a decade ago.

Primary care is struggling to deliver the traditional model of general practice, where the same type of care is offered to all patients, regardless of their medical and social needs.  This project will investigate whether there is a better way to ensure GPs are seeing the most appropriate patients, and where they can have the greatest impact.

A stratification tool will be developed and implemented at Dickens Place Group, a practice of 14,000 patients currently based across three sites. It will identify those patients with the greatest need for continuity and coordination of care. It will look at the presence of long-term conditions and social care need, defined by age, frailty, vulnerability and safeguarding issues.

The stratification will involve a search of coded patient data held in the GP practice’s IT system, and a secondary stratification by clinicians identifying a smaller cohort of patients with the most complex needs. 

Patients will be segmented into three tiers, and the tool will update regularly, to reflect changes in patients’ circumstances.

Pre-emptively knowing the potential workload of each tier will allow staffing to be adjusted across the tiers. GPs will then be concentrated around care for the most complex patients, using new roles such as care navigators to support them; allowing nurse practitioners to focus on less complex patients. 

Contact information

For more information about this project, please contact Sharon Kendall, Managing Partner, Dickens Place Group.

About this programme

Programme

Innovating for Improvement

This programme supports up to 23 projects with up to £75,000 to test and develop innovative ideas and approaches, put them in...

You might also like...

Improvement project

Developing Innovative clinical pathway for women with Autism spectrum features and Eating Disorders (DIAED)

This project will involve developing recommendations for a structured pathway for women with autism spectrum disorder and ano...

Improvement project

West End Wellbeing: a place-based multidisciplinary approach to meeting needs in Newcastle’s West End

This project is aiming to enable staff and organisations to work together in a multidisciplinary way to better meet the needs...

Improvement project

Changing the conversation: developing an alliancing approach to whole system transformation of health and care

This project is aiming to transform service delivery to meet the growing health and social care needs of the South Wales popu...

Kjell-bubble-diagramArtboard 101

Work with us

We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.

View current vacancies
Artboard 101 copy 2

The Q Community

Q is an initiative connecting people with improvement expertise across the UK.

Find out more