Clinical Risk vs. Clinical Need: managing workload and throughput

At the beginning of the year I attended a two day training course: “Advanced Clinical Reasoning and Effective Clinical Decision Making”, facilitated by Kate Malcomess. It was an intense two days, at the end of which my brain hurt!

Kate talked a lot about risk, which she defines as, “the degree to which harm is foreseeable.” This led us to think about who can best manage a child’s risk, which is linked to the three levels of care: universal, targeted, and specialist. At the universal level—that is, for all children—we should be supporting parents to enable them to manage their child’s risk.

We discussed clinical risk, “the degree to which foreseeable harm can be managed by your intervention,” which you can think of as effectiveness. Then there’s clinical need, “the input needed to reduce risk and achieve predicted outcomes, ” which approximates to the amount of clinical input needed. Kate suggests using a clinical risk vs. clinical need grid, to prioritise workload and increase throughput.

Let’s consider a child who has both high clinical risk and high clinical need. An SLT can effectively reduce risk for this child, but a large amount of input is required. In contrast, a child who has high clinical risk but low clinical need, requires only a small amount of input for risk to be effectively reduced.

If we prioritised these high clinical risk, low clinical need children we would increase throughput: the number of children moving through the system, i.e. the children whose referrals are accepted, are assessed, offered intervention and then discharged. Currently it seems like most children are stuck at the intervention stage—we don’t discharge many, so throughput is small. If we could increase throughput, we would reduce waiting times, which may lead to more cheerful parents (and therapists!).

This way of thinking turns the traditional model, that I’m used to, on its head—there is no mention of using severity to make these types of decisions.

So how do we start? Kate talked about caseload profiling as a first step: looking at where on the risk vs. need grid we would place the children currently on the caseload. Then we can work on throughput, while keeping a record of unmet needs, to show to our commisioners. It’s going to be a lot of work, but I’m looking forward to the challenge, and want to start making some changes… I’ll keep you updated!

10 thoughts on “Clinical Risk vs. Clinical Need: managing workload and throughput

  1. Alison

    I’m currently doing some research about SLTs experiences of using the Care Aims Model. Would be interested to hear others views

  2. Rhiannan Walton Post author

    Hi Alison,

    Thanks for your comment. That sounds interesting. What types of questions are you asking? Maybe we could post them up here.

    The service I work in is just starting to implement some of Malcomess’ ideas, I’d be happy to help out.

  3. Lisa

    The service I work in is has implemented some of Malcomess’ ideas too.

    As a result of the training we now meet with peers to analyse our caseloads. We ask ourselves the following questions in order to help us reflect on our caseloads using Kate Malcomess principles:

    1.What is the patient’s current status e.g. regular therapy, review etc.?

    2.When was the patient last seen?

    3.If the patient was last seen more than 6 months ago, what are the clinical reasons for them still being current on the caseload?

    4.When will the patient be seen again?

    5.When is the patient planned for discharge?

    I have found this really helpful for thinking about clinical risk vs clinical need and maximising throughput. Our service preferred to answer these questions rather than use the grid system recommended by Malcomess.

  4. Rhiannan Walton Post author

    Hi Lisa,

    Thanks for your comment. Those questions look really useful.

    I particularly like question 5!

    We are re-establishing peer supervision, so I will take your questions along and try them out.

  5. Lisa

    Hi Rhiannan,

    Personally I find question 5 the most difficult to answer but also the most useful! I usually think in terms of whether a case is likely to be short medium or long term but am aware this is still very subjective!

    Hope you do find answering the questions useful. Let me know how you get on and what you find / do not find useful, or any alterations you made.

    Lisa

  6. Clare Grace

    Hi Rhiannan and Lisa,
    Our Trust has undertaken the 2 day training and we are about to have our follow up day in April. I have been given the lead in my service to help start implementing Care Aims across the SLT service. I am trying to make links with other services going through this process – so it was great to find this blog!
    We are undertaking case discussions at the minute – and mapping them out against the ‘What is my Duty of Care to Referred people’ flow chart. We look at a new referral and guess predictatvely where it will go, then we discuss an older case and look retrospectively how it would fit.
    My biggest conundrum at the minute, is that the risk assessment tools are very medical model – and don’t seem to reflect anything within the tools/structures of education – and 80% of our caseload is working into an educational setting – any thoughts or ideas would be greatly appreciated.
    Clare

  7. Pingback: Care Aims in education vs. medical model — Therapy Ideas blog

  8. arianna

    This comment is directed to Alison – I wonder if you might leave contact details – I’m interested in finding out more about your research with SLTs and the Care Aims approach, thanks you can contact me at [email protected]

  9. Mark Harrison

    I work within a trust that has adopted the care aims approach, and I am now undertaking training in order that I can train staff new to our trust.
    I have been usung the model/approach for approximately 9 months and find that it is enabling our team to manage referrals more efficiently (i.e. reduce inappropriate referrals), manage patients expectations more easily (by patient centred, transparent goal setting with a clear care aim) and facilitating timely discharge from our service. For Clare who asked about assessment tools, I am trialing Therapy Outcome Measures as both a baseline assessment and outcome measure, its domains include both medical and social aspects of function. e.g. impairement and participation are two. By the way, I am an Occupational Therapist on a Falls Prevention Service and address environmental, cognitive, ADL and confidence issues.

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