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1: Risk Profiling

Primary care should be at the heart of the delivery system and that system should focus on prevention not just treatment. The healthcare system needs to focus on total population health within long term conditions not just respond to the needs of individual patients. We need to shift from a reactive hospital based system of unscheduled care towards one which is founded on a preventive, anticipatory approach to managing long term conditions on a whole-person basis. A first step is to stratify your local population in terms of their pattern, seriousness and complexity of long term conditions to identify those individuals most at risk of future crises. Ambulatory case sensitive conditions are illnesses, mainly long term conditions, for which hospitalisation is felt to be avoidable. This cohort of people forms the basis of the target population which evidence suggests should receive adequate, safe care in a primary or community care setting.


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Source: (2) Conn, Valentine & Cooper “Interventions to increase physical activity among aging adults: a meta-analysis”. Ann Behav Med 2002; 24(3): 190-200

Source: (3) Fagerberg, et al. “Effect of acute stroke unit care integrated with care continuum versus con-ventional treatment. Stroke 2000; 31(11): 2578-84

Billings, J., J. Dixon, T. Mijanovich and D. Wennberg (2006), „Case finding of patients at risk of readmis-sion to hospital: development of algorithm to identify high risk patients‟, British Medical Journal, 333: 327–330.