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Segmentation & Risk Stratification

Graphnet is uniquely positioned to support organisations to undertake patient segmentation and risk stratification. Our population health solutions bring a substantial amount of information into a centralised location to enable effective and automatic modelling.

Access to a rich pool of data and population health analytics tools means segmentation can be performed based on characteristics such as age, gender, and specific diseases but also on morbidity and healthcare utilisation patterns. Individuals can then be stratified within a specific subpopulation according to the risk of experiencing an adverse event, such as defined undesirable health outcomes or the extent of their healthcare utlisation.

From risk stratification to prevention: Our end-to-end solution enables the identification, classification and prevention of care deficits. Risk stratification engines can be integrated to enable the early detection of patients at risk or those who have negative health trajectories. Automated ‘what-if’ models can give clinicians lists of preventive and reactive models driven by data and evidence.

Cohort mapping engine build localised registries: The cohort mapping engine delivers standardised diseases and wellness registries. The engine also gives users the ability to include their own mappings which enables localisation.

Frailty: The electronic frailty index (eFI) delivers the ability to stratify the entire elderly population. Frailty deficits are calculated and a full history for each patient can be analysed.

Data and model APIs: Our APIs allow the integration of our business intelligence and data science packages with third party tools, and vice versa. Following the REST API structure means that our APIs enable easy to use industry standard integration with third party applications.

Graphnet also works closely with Johns Hopkins HealthCare Solutions. The Johns Hopkins ACG System, a risk stratification model designed by Johns Hopkins University, can be integrated into Graphnet’s population health platform. It supports the work of clinical teams through the accurate identification of the right people for the right care management intervention. It assists ICSs in their strategic planning through a more granular understanding of how risk and disease prevalence is distributed within their populations and to support a more sophisticated approach to allocating resources to reflect need and reduce inequity.

Use Case: Easing fuel poverty in Cheshire & Merseyside

The Cheshire and Merseyside Integrated Health and Care Partnership has used population health to identify more than 1,300 people who are at risk of developing serious health issues due to fuel poverty. Data has allowed them to stratify their fuel-poor population using risk of admission, mortality risk and other factors such as living alone, allowing support to be delivered where it’s needed most.

As of February 2024, 213 patients have been contacted through the St Helens WarmHomes for Lungs project and referred to St Helens Councils Home improvement team, resulting in 106 referrals to the Wellbeing Team, 20 referrals to the Pulmonary Rehabilitation (PR) Team, 20 patients have been onboarded to the COPD Telehealth Service, and 169 patients have received £500 payments from household support funds.

A total of £ 84,500 in payments have been made, and all patients have been reviewed by the specialist nursing team and offered a pulse oximeter and a warm home pack including a vitamin D Voucher. On top of that, 43 patients have received a second payment of £500 (totalling £21,500).

Read the full case study here