This document summarizes a project using the SPARRA tool and Gold Standards Framework approach to identify and manage complex patients at risk of hospital admission in Angus, Scotland. Key findings include: - SPARRA identified some at-risk patients but missed others known to professionals and 40% of the SPARRA list were already identified in preliminary studies. - A pilot project at one practice used SPARRA and a "top ten" list to implement Gold Standards Framework care planning which improved communication between professionals and reduced emergency care contacts. - Further work cross-referenced SPARRA lists with existing case management services to better identify and share information on complex patients.

1. Sharing our Experiences of Using
SPARRA
Rhona Guild
Primary Care Manager
Angus Community Health Partnership
(CHP)

2. NHS Tayside
Population

4. Angus Demographics
• Total population 109,320
• Lower than Scottish average population
of working age
• Higher life expectancy in both men and
women
• 0.8% ethnic minority population
• All cause mortality and heart disease
mortality lower that Scottish average and
cancer mortality amongst lowest in
Scotland.

5. Demographics (continued)
• Proportion of population hospitalised
for alcohol or drug related causes
amongst lowest in Scotland
• Significantly lower rate of acute
admissions
• Lower levels of homelessness
• Lower levels of deprivation
(Source: Scot PHO Health & Wellbeing Profile, 2008)

7. The Angus Journey

8. The Angus Journey in Complex Care
Management: Step One
•Preliminary studies
within general
practices in 2006,
reviewing complex
care pts on basis of
Uniquecare criteria

9. Key Findings from Preliminary
Studies
• Patients identified through this process all
deemed as complex by professionals
involved
• Patients were not high users of
unscheduled care
• All patients proactively managed within
general practice, with impact of QoF
evident

10. • Recurring themes in those who did
have > unscheduled care ( COPD,
mental health and/or alcohol issues)
• Issues in entire adult population, not
particular to older age groups
• Key issues related to coordination of
services between primary and
secondary care

11. Uniquecare Criteria vs SPARRA
• Scottish Patients at Risk of Readmission
and Admission identified fewer pts than
Uniquecare approach (focussed on >65’s)
• 40% pts on SPARRA list had been
identified by initial approach
• 27% pts on SPARRA but not in initial
approach had died
• Of remaining 33% pts on SPARRA but
not in initial approach, renal issues was a
predominant feature. Implications of QoF
coding also noted

12. Uniquecare vs LA Care
Management
• Small numbers receiving complex care
packages within LA
• 17% pts with complex care packages <65
yrs, 73% >65 years.
• Many had just one long term condition,
with an impact on ability to self manage
• Stroke a predominant feature

13. Heart Disease
Mental Health
Circulatory
Ill Defined
Digestive
Cancer
Injuries
COPD
Other
Resp
Townhead Practice
Patients with 70-90% Risk of Admission
Springfield MC - West
Springfield MC - East
Ravenswood Surgery
Monifieth HC
Lour Rd Gp Practice
Kirriemuir HC
Friockheim HC
Edzell HC
Castlegait Surgery
Parkview
The Angus Journey: Step 2
Brechin HC
Arbroath MC
Annat Bank Practice
Academy MC
Abbey HC
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Patient Numbers
Early SPARRA
Total Number of Patients at Risk of Admission
Townhead Practice
Springfield MC - West
Springfield MC - East
Ravenswood Surgery
Monifieth HC
Lour Rd Gp Practice
Kirriemuir HC
Friockheim HC
Edzell HC
Castlegait Surgery
Parkview
Brechin HC
Arbroath MC
Annat Bank Practice
Academy MC
Abbey HC
5.0%
4.5%
4.0%
3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Pop
As a % of Practice

14. The Angus Journey: Step 3
Gold Standards Framework for LTC’s
in General Practice
•The Gold Standards Framework (GSF) is a
‘systematic evidence based approach to
optimising the care for patients nearing the end
of life in the community’.
•The focus of GSF is to improve care in the
community by optimising the local primary care
team’s provision, so that more patients are
enabled to live and die where they choose, and
un-needed hospital admissions are avoided.

15. 3 processes of GSF include:
• Identification of patients in need of
palliative/supportive care
• Assessment of needs, symptoms,
preferences etc
• Care planning and delivery.

16. 5 GSF Goals:
• Good symptom control.
• Patients enabled to live and die well in
their place of choice.
• Better advanced care, planning,
information, less fear, fewer crisis/hospital
admissions.
• Well supported and informed carers.
• Staff confidence, communication and co-
working.

17. Aims of GSF Project for LTC’s
•To explore the impact
introduction of the Gold
Standards Framework (GSF)
in the management of
complex Long Term
Conditions Management,
within primary care, had on
patient outcomes and staff
satisfaction

18. Pilot Details
• Based in Academy Medical Centre,
Forfar
• Large teaching practice
• Practice population 10990
• 81% being under the age of 65
• 19% over the age of 65.
• Multi-agency participation
• 2008-9

19. ‘Top Ten’: Identification
• Identified through SPARRA and Tayside
Predictive Tool
Or
• Recommendation of patients by core team
member and approval by others
• Any adult eligible for inclusion and the
project did not focus exclusively on any
given areas of priority from a disease, multi-
disease or age perspective

20. Project Plan
• Education of staff re aims of complex care
management, & GSF
• Core list of ‘top ten’ agreed by core team
• Inclusion in supportive care register
• Monthly meets aimed to improve the flow of
information, advance care planning and
measurement/audit of outcomes
• Shared care planning

21. Our Top Ten!
Pati Age Long Term How Services at New Emergency Emergency
ent Conditions Identified? Outset of services or Care Care
No (List all) Sparra/PEONY Project changes to Contacts Contacts
/ eg GP, DN care as a 6/12 pre-pilot 6/12 during
Team/Other result of pilot
pilot
Eg 85 CHD District Nurse DN Care 10 5
Diabetes Not on GP management
SPARRA
1 69 DIABETIC PN PN 3 0
HYPERTENSI
ON
2 61 CHD CM CM+DN 0 0 and no
MS GP visits
3 79 COPD SPARRA PRACTICE 2 2
CKD
4 68 COPD DN ALL DIED DIED DIED
CKD
5 74 DIABETIC DN DN + CM 2 2
HYPERTENSI
ON
COPD
6 83 HYPERTENSI DN DN 0 0 and 0
ON OOH
CHD callouts
COPD
CKD

22. Patie Ag Long Term How Identified? Services at New services Emergency Emergency
nt e Conditions Sparra/PEONY/ Outset of or changes to Care Contacts Care
No (List all) Team/Other Project care as a result 6/12 pre-pilot Contacts
eg GP, DN of pilot 6/12 during
pilot
7 59 DIABETIC DN DN PN 0 0 and 0 OOH
CHD callouts
CKD
8 82 HYPERTENSION CM CM + DN 1 0 and 0 OOH
CHD callouts
9 67 HYPERTENSION CM CM 3 0
MS
10 78 CHD SPARRA CM + 2 0 and 0 OOH
PRACTICE callouts
TOTALS 13 4

23. Q1. In your opinion, has this project improved
communication between the professionals involved
in the care of the patients included?
0%
Yes
No
DNA Q2. Has your understanding of the roles
100% performed by other professionals involved in the
project improved as a result of this project?
14%
Yes
14%
No
DNA
72%
Q11. Do you feel that this project has been a
success?
0%
Yes
No
DNA
100%

24. Staff Views on Most Effective Means
of Pt Identification
• ‘Case discussion. SPARRA chose patients that were
deceased or had very little input from both social work and
health’
• ‘I decided to use the SPARRA data as a tool for identifying my
patient. This proved ineffective due to its basis on
retrospective data and in fact my patient had no admissions or
GP contacts during the duration of the pilot despite multiple
co-morbidities and numerous preceding issues, which required
MDT work.’
• ‘SPARRA search and individual proposal of suitable patients.
Some patients we felt who would be suitable for inclusion did
not appear on the electronic search’
• ‘Individual/team knowledge’
• ‘Best “mechanism” for patient identification was without doubt
the DNs!’

25. The Angus Journey: Step 4
• Cross reference of SPARRA lists with
existing care/case management
services, to aid dissemination of
information/use of data
• General Practice : Quality &
Outcomes Framework +
• COPD Anticipatory Care Project

26. COPD Anticipatory Care Project
All COPD patients All COPD patients Clinical agreement
registered with registered with Montrose of suitability of any
Montrose practice practice with COPD other COPD
with COPD related
identified by SPARRA as patient registered
admission during
period of pilot being at risk of recurrent with Montrose
admission practice
Agreement of inclusion of patient in anticipatory care project by
clinicians with links with Palliative Care DES and advice from other
agencies where appropriate.
(Maximum caseload to be agreed, approx 15 patients at any given
time)
1. Holistic assessment by COPD nurses offered to all patients identified
through SPARRA or team, who have not had a COPD assessment by
housebound service within last 6 months.
2. In addition to normal care, all COPD related discharges will receive a
joint assessment visit by DN and COPD housebound nurse on the
next working day after discharge (even where ESD in place).
1Care plans to be developed, with a focus on patient goal setting and self management
education, using the BLF COPD Self-Management Plan in all cases, and Palliative Care
DES information if appropriate.
2 Anticipatory care planning for all patients, including recording of information in OOH
systems.
3 Urgent referral to pulmonary rehabilitation if appropriate.
4 Standardised community and COPD housebound nursing documentation to be used.
5 Ongoing implementation of care plan, with minimum of 3/12 review.

27. Criteria Pt1* Pt2 Pt3* Pt4* Pt5*
Smoking status     
Smoker Smoker Smoker
Immunisation status     
Assessment of MRC 3 3 2 2 3
dyspnoea score
Medication review     
Inhaler technique     
Education     
Self-management     
BLF booklet BLF booklet BLF booklet BLF booklet BLF booklet
Co-morbidities     
Assessment of     
psychological co-
morbidity
Anticipatory care     
planning on Taycare on Taycare on Taycare on Taycare on Taycare
Others Taxicard Referral for anxiety mgt OT referral Meds changes Smoking cessation
Rescue meds New devices Exercises Devices changes advice
Exercise advice Referral to pulmonary Rescue meds New devices
rehab CMT referral Meds changes
Exercise on referral
Referral to pulmonary
rehab
Status at end of On DN service books Admitted onto DN Admitted onto DN Discharged Discharged back to PN
project prior to project. Care caseload & COPD caseload & COPD
ongoing Housebound service Housebound service

28. Pt6* Pt7 Pt8* Pt9
Smoking status    
Smoker
Immunisation Status    
Assessment of MRC 4/5 3 5 4
Dyspnoea Score
Medication Review    
Inhaler Technique    
Education    
Self Management    
BLF booklet BLF booklet BLF booklet BLF booklet
Co-morbidities    
Assessment of    
Psychological Co-
morbidity
Anticipatory Care    
Planning on Taycare on Taycare on Taycare on Taycare
Others Rescue meds Rescue meds Meds changed Flu vac
Continence assessment Flu vac Rescue meds Referral to pulmonary
Oral thrush identified and tx, Inhaler technique rehabilitation
and oral hygiene taught Dental referral Rescue meds
Commenced antidepressants Referral to pulmonary rehab
Reliant of nebulisers
Taught re use of
aerochamber
Portable O2 arranged for
holidays
Status at End of Project On DN service books prior to Discharged back to PN On DN service books prior to Admitted onto DN caseload
project. Care ongoing project. Care ongoing & COPD
Housebound service

29. General Observations Regarding
SPARRA
•Accuracy of data sources
•1/4rly report limiting
•? Finding patients too late?
•? Disadvantaged by lack of GP data feed?
•Variable use of SPARRA data
To effectively implement and evaluate systems
for complex care, we need a tool to effectively
identify those who we can effectively make a
quantitative as well as qualitative impact

30. Next??
•Virtual wards
•QoF+
•? Enhanced service
within general
practice