Patient identification

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All Health Care Home providers will use the same risk stratification tool to identify eligible patients and place them in the appropriate tier.

The risk stratification tool will be developed by Precedence Healthcare.

The tool will identify patients who are eligible to enrol and further assesses those patients’ risk factors, including the likelihood of unplanned hospitalisation.

Further narrowing of the resulting list will be done by clinicians at the clinic who will assess the clinical and non-clinical factors that affect their patients’ health.

Patients will be asked for their consent to use their health and personal information for these purposes.

Data checklist

The risk stratification tool will only look at data that is coded. So the more coded data you have, the larger the patient cohort it will be able analyse. Use this checklist to find areas you need to work on:

  1. Demographics
    • are the contact details up-to-date?
    • double-click on the patient’s telephone number to check & update details.
  2. Medication List
    • is the current medication list accurate?
    • right-click to delete/cease medications no longer relevant  (ceased or deleted meds can then be found in the Old/Past Scripts section)
    • if none, tick No medications
  3. Past History List
    • does it contain only significant conditions that a hospital or specialist would need to know?
    • right-click to edit, delete or add new
    • If none, tick No significant past history (PMH) box
  4. Allergies
    • have you also recorded adverse reactions?
    • double-click in allergies box and Add, Edit, Delete
    • if none, tick No Known Allergies/Adverse Reactions/Nil Known
  5. Immunisations
    • have immunisations been recorded?