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RISK STRATIFICATION TOOL Diagnosis / Health assessment Stream A Stream B2 Stream C Self Care pathway Acute Deviance from Wellbeing (time limited) Chronic Deviance from wellbeing (Long Term) Shared care (Primary and secondary care) with patient as co-producer Led by: Secondary care with primary care and the patient as co –producers Led by: Patient Primary care •Condition stable (blood sugars stable) •Individual management targets achieved or improving •Compliant with medications and treatment •Responding to current management •Condition has become unstable and has not responded to primary care change in treatment •Onset of acute complications •Admission to hospital for a related condition •Inability to achieve / no improvement towards targets •Reduction in independence •Multiple complications •Multiple long term conditions •Unable to cope / reduction in independence •Inability to stabilise condition • On maximum treatment •Multiple hospital admissions