Improving management of high cost patients, especially those with long term conditions, it is increasingly viewed as an important strategy for improving health outcomes and controlling health care expenditures. An essential component of any strategy to improve care and services for these patients is the development of a case finding mechanism to identify high risk patients as early as possible to enable interventions to be targeted before substantial preventable/avoidable expenditures have been incurred and health status has deteriorated further. [Introduction].