Risk Indicators

SHIIP leverages several risk scores, assessment scores, and status flags to indicate that a patient may require a higher level of care.

Complex Patient Flag

Roughly five percent of patients account for more than sixty percent of health care costs. SHIIP aims to identify these patients so that we can enable focused care coordination and provide more effective care. Additionally, identifying these patients aims to reduce the costs associated to readmission. Although there is no formal definition of a complex patient, Ontario health agencies & organizations have developed a similar list of characteristics that we use to define patient complexity:

  • The presence of four (or more) chronic and/or high-cost conditions with a focus on conditions related to mental health and addiction.
  • At least one problem relating to social determinants, such as; housing, immigration, social services, etc.

SHIIP identifies complex patients using only the first characteristic. It’s important to note that this is not a deciding factor when determining a patient’s eligibility for care coordination. Some patients identified as complex may not be suitable, whereas others considered non-complex may be suitable.

A list of the complex conditions are below:

(Congestive) Heart FailureALS and Motor Neuron DisordersAmputation
AnemiaAnxiety disordersArthritis and related disorders
AsthmaBipolar disorderBrain injury
Cardiac ArrhythmiaCerebral PalsyChronic Obstructive Pulmonary Disease
Coagulation defects and purpuraComaCongenital Malformations
Crohn's disease / colitisCystic FibrosisDementia
DepressionDevelopmental disordersDiabetes
Eating disordersEpilepsy & seizure disordersFracture
Hemiplegia / HemiparesisHerniaHIV / AIDS
Huntington's choreaHypertensionInfluenza
Ischaemic heart diseaseLiver disease (cirrhosis, hepatitis etc.)Low birth weight baby
Multiple sclerosisMuscular dystrophyNeoplasm
Osteoporosis including pathological bone fractureOther mental healthOther perinatal conditions
Pain managementPalliative careParalysis (paraplegia or quadriplegia) and spinal cord injury
Parkinson's diseasePneumoniaRenal failure
Schizophrenia & delusional disordersSepsisStroke
Substance-related disordersUlcer


Hospital Admission Risk Prediction (HARP)

HARP is a tool co-developed by Health Quality Ontario (HQO) and the Canadian Institute for Health Information (CIHI). HARP helps health care providers identify patients that are at risk of future hospitalization. This supports healthcare professionals by allowing early intervention for difficult health episodes. It also assists in predicting which patients will have the biggest draw on health system resources. This information helps primary care providers identify destabilizing patients that could require additional care or support.

HARP generates a patient’s risk score within two time frames – 30 days and 15 months. SHIIP takes advantage of the most current patient information alongside the HARP methodology to provide an accurate chart. The HARP methodology accounts for a number of variables that can predict future hospitalization. These variables were determined by HQO and CIHI via thorough analysis of acute care and social data variables.

LACE Index

The LACE Index identifies patients that are considered at risk of readmission or death within 30 days of discharge. There are four key parameters used to determine a LACE calculation:

  • Length of stay
  • Acuity of admission
  • Co-morbidities
  • Emergency department visits

These parameters generate a score, and are categorized as follows:

  • 0 to 4 (The patient is at low risk of readmission or death within 30 days of discharge)
  • 5 to 9 (The patient is at moderate risk of readmission or death within 30 days of discharge)
  • 10 to 19 (The patient is at high risk of readmission or death within 30 days of discharge)

SHIIP shows the patient’s current LACE score in a number of locations, including the Risk Profile where users can see the score evolve over a specified time period.

Assessment Urgency Algorithm (AUA)

AUA is an assessment tool used to determine if a patient will require special geriatric services, home care, or hospital admission. An AUA score can range from one to six. It takes several factors into consideration, including:

  • Self-reliance
  • Self-rated health
  • Difficulties breathing
  • Family’s ability to assist
  • Self-rated mood
  • Support in daily activities

Canadian Triage and Acuity Scale (CTAS)

CTAS is a tool that supports emergency departments in the prioritization of patient care requirements. It also assists emergency departments in the examination of patient care processes, workload, and resource requirements relative to case mix and community needs. CTAS has a number of benefits for nurses, physicians, and managers in emergency departments. CTAS levels range from one to five:

  • Level 1 – Resuscitation
  • Level 2 – Emergent
  • Level 3 – Urgent
  • Level 4 – Less urgent
  • Level 5 – Non urgent

Modified Caregiver Strain Index (MCSI)

MCSI is a tool that can be used to identify families that have potential care giving burdens. It is a simple questionnaire that measures strain related to care giving. These questions include the following subject areas:

  • Employment
  • Financial
  • Physical
  • Social
  • Time

MCSI can be used to assess patients at any age who have assumed the role of a caregiver for an older adult. Positive answers to several or more questions indicate a high level of caregiver stress.

Method for Assigning Priority Levels (MAPLe)

MAPLe is a tool that can be used to prioritize patients needing either community-based or facility-based services. This tool helps plan the allocation of resources for a patient. Key use cases of MAPLe are it’s ability to predict admission to residential care and caregiver distress.

MAPLe consists of five priority levels. The level assigned is determined by considering a broad range of criteria, which include:

  • Worsening of decision-making
  • Behaviour
  • Meal preparation difficulty
  • Medication management difficulty
  • Falls
  • One or fewer meals a day
  • Swallowing
  • Pressure or stasis ulcers
  • Environment
  • Number of medications
  • ADL Self-Performance Hierarchy Scale
  • Cognitive Performance Scale
  • Institutional Risk CAP
  • Geriatric Screener

Resource Intensity Weights (RIW)

RIW is a value that represents the relative resources used by a patient. Furthermore, it is a value that can represent the expected resources usage of a patient. This weighting can be adjusted to account for variables (i.e. a patient’s age).

Social Determinants of Health (SDOH)

SDOH are the primary factors that contribute to the health of Canadians. They are not medical treatments or lifestyle choices, but rather the living conditions in which someone lives. The following factors are used to determine a patient’s SDOH:

  • Income and income distribution
  • Education
  • Unemployment and job security
  • Employment and working conditions
  • Early childhood development
  • Food insecurity
  • Housing
  • Social exclusion
  • Social safety network
  • Health services
  • Aboriginal status
  • Gender
  • Race
  • Disability

These factors are extracted from Canadian census data so that SHIIP can determine a patient’s SDOH values in SHIIP. We break these values into three scores; material deprivation, social deprivation, and combined deprivation.