Approaches to case finding:models and applicationManaging referral rates andreducing admissions
IntroductionOuter north east London have implemented two risk basedapproaches to case finding in order to reduce hospital ...
Population • Clinical risk targetingLaura OsbornPlanning and Delivery Project ManagerNHS North East London and the City
Outline and aims Risk stratification  • Identifies those most at risk of emergency admission - top 1% risk Partnership wor...
Integrated care model of care      Identify    Service User                                   Case Conference             ...
The integrated care team                                      GP End of Life                                              ...
Risk profiling for integrated care  Use Health Analytics  • Combined Predictive Model  Commissioning tool  • Integrated el...
Functionality Segment by : •   Risk score •   Age •   Emergency admissions and attendance •   Cost (primary and secondary)...
Risk profiling for Integrated Care:Modelling the clusters The data from Health analytics enabled us to group the practices...
Risk profiling for integrated care:Selecting the cohort                        Identify top 1%                         ris...
Identifying the highest risk patientsWithin the top 1% there is a significant variance inrisk scores – we are able to sort...
Outcomes   Over 1300 patients with MDT care plans in place   132 GP practices, 3 local authorities, 2 acute trusts and  ...
Disease             •Disease risk analyticsRobert MeakerAssociate Director for CommissioningSupport and InnovationNHS Nort...
Why Chronic Obstructive PulmonaryDisease ?                           Chronic Obstructive Pulmonary Disease (COPD)       Di...
High Cost –Secondary Care Use Practice 1   Practice 2   Practice 3   Practice 4   Practice 5   Practice 6   Practice 7   P...
Intention • Defining quality “Risk factors” – NICE Quality Standards   for COPD • Measuring Quality= Health Analytics data...
Identification of Interventions Establish and monitor a set of 7 core areas for patient care, within primary care. 1) Post...
Interventions to reduce risk (Quality)
Impact of Interventions  100   90   80   70   60   50   40                                                     Pre   30   ...
Impact on COPD Admissions1200                                                                                             ...
Intervention stage 2                     Patient empowerment             Promote improvement through patients    Send each...
Learning• Define Patient Risk factors “Quality Care”• Measure Quality Care• Multi Level Educational Intervention•   Data r...
Prochain SlideShare
Chargement dans…5
×

Approaches to case finding: models and application

859 vues

Publié le

Publié dans : Santé & Médecine, Business
  • Soyez le premier à commenter

  • Soyez le premier à aimer ceci

Approaches to case finding: models and application

  1. 1. Approaches to case finding:models and applicationManaging referral rates andreducing admissions
  2. 2. IntroductionOuter north east London have implemented two risk basedapproaches to case finding in order to reduce hospital admissionsand referrals • Clinical risk Population targeting • Disease risk Disease analytics
  3. 3. Population • Clinical risk targetingLaura OsbornPlanning and Delivery Project ManagerNHS North East London and the City
  4. 4. Outline and aims Risk stratification • Identifies those most at risk of emergency admission - top 1% risk Partnership working • Between the GP practice, Social services and provider services. Avoid duplication • Services, resources and patient contacts Proactive management • Long term conditions and social needs Prevents avoidable hospital admissions • Robust planned care and patient education in the community
  5. 5. Integrated care model of care Identify Service User Case Conference Care Plan Health Analytics used to identify top 1% of Fortnightly cluster meetings held. patients at risk. Attended by core team Team agrees action plan for Clinical judgement Meetings approximately 45 each patient used to supplement minutes. the risk stratification 2-3 new patients plus other tool. existing patients discussed. Self ManagementPatient is providedwith information on Care Plan Review Care Deliverywhat to do in case ofemergency Care plan shared with MDT and Community Matrons undertake an discussed at next meeting. assessment of the patient . Onward Referral The MDT team reviews the care Members of the MDT provides Patient referred to plan and agrees if other measures patient with the necessary care to supporting services need to be put in place to prevent prevent admission. in the community the admission. Liaison officer follows through with Ongoing Care The team risk rates the patient patient and MDT to ensure service and agrees a follow-up period. is provided.Patient kept on theregister for a periodof 6 months for on-going care. 5
  6. 6. The integrated care team GP End of Life Mental Care health Community liaison Matron officer Service Therapies Practice User Third Sector Nurse Social Worker (Optional) District Drug & Alcohol Nurse services Acute care specialists
  7. 7. Risk profiling for integrated care Use Health Analytics • Combined Predictive Model Commissioning tool • Integrated electronic solution for patient care information Multi functional tool • Integrates care data from any source • Financial and clinical data
  8. 8. Functionality Segment by : • Risk score • Age • Emergency admissions and attendance • Cost (primary and secondary) • Specific long term conditions Role-based access Electronic care plan functionality
  9. 9. Risk profiling for Integrated Care:Modelling the clusters The data from Health analytics enabled us to group the practices into the ‘clusters’ depending on location & number of high risk patients in the cohort. This also allowed us to work with community providers and social care to begin work aligning the teams Number of Practice List Size patients in HA top 1% Practice 1 7798 167 Practice 2 7425 122 Cluster 1 Practice 3 3246 54 Practice 4 3686 61 Practice 5 5103 97 Practice 5 5200 82 Practice 6 4348 47 Practice 7 12498 204 Practice 8 10378 152 Cluster 2 Practice 9 4724 46 Practice 10 6394 39 Practice 11 4222 38 Practice 12 3082 56 Practice 13 2748 26
  10. 10. Risk profiling for integrated care:Selecting the cohort Identify top 1% risk segment – Modelling 4239 in Redbridge indicates that 90% of these will have one or more LTC Reviewed by Integrated Care team – accepted if suitable These people accepted into Integrated Care will then be discussed by the team and a care plan will be developed across both health and social care
  11. 11. Identifying the highest risk patientsWithin the top 1% there is a significant variance inrisk scores – we are able to sort the patients inorder of risk score to ensurethe highest risk patients are considered first forcase management Bottom 10 risk Top 10 highest scores in risk scores in the top 1% the top 1% (Average (Average Emergency Emergency Admissions Admissions 6.4) 0.1)
  12. 12. Outcomes Over 1300 patients with MDT care plans in place 132 GP practices, 3 local authorities, 2 acute trusts and 1 community provider delivering the model of care Improved co-ordinated care by multi-disciplinary teams and reduced duplication Every patient has a nominated and dedicated liaison officer to coordinate personalised care Rapid access to social care as needed through direct referral to social care Co-location of health and social care teams in B&D and Redbridge building “high trust” partnership teams
  13. 13. Disease •Disease risk analyticsRobert MeakerAssociate Director for CommissioningSupport and InnovationNHS North East London and the City
  14. 14. Why Chronic Obstructive PulmonaryDisease ? Chronic Obstructive Pulmonary Disease (COPD) Direct healthcare cost of over affects around 4% of the adult 10 % of emergency admissions 1 £950,000,000 1 population. 1 14 % admitted patients die 1 Indirect costs of £1,300,000,000 1 Highest costing individual with COPD over 2 years £50,299 2 35 % are readmitted within 90 days 1 2 year cost of COPD in Barking & Severe mean, 10 care visits £8,000 Dagenham £5.5 million 2 p.p. 11 2 Source European respiratory Society Source ONEL business intelligence
  15. 15. High Cost –Secondary Care Use Practice 1 Practice 2 Practice 3 Practice 4 Practice 5 Practice 6 Practice 7 Practice 8 Practice 9 Practice 10 Practice 11
  16. 16. Intention • Defining quality “Risk factors” – NICE Quality Standards for COPD • Measuring Quality= Health Analytics data extraction system installed in each surgery • Education programme at multiple levels – offering support where needed and wanted • Empowering patients
  17. 17. Identification of Interventions Establish and monitor a set of 7 core areas for patient care, within primary care. 1) Post bronchodilator spirometry 2) Severity Measurement 3) Annual review 4) Smoking cessation 5) Pulmonary rehabilitation 6) Self management plan 7) Palliative care The Health Analytics tool, identified a 10 fold baseline variation between practices on many quality measures
  18. 18. Interventions to reduce risk (Quality)
  19. 19. Impact of Interventions 100 90 80 70 60 50 40 Pre 30 Post 20 10 0 Spirometry Self Management Ref. PR Confirmed Plan Issued Diagnosis Key Indicators Pre and Post Intervention 45 Practices with 2788 Registered COPD Patients
  20. 20. Impact on COPD Admissions1200 Number of patients not diagnosed with COPD by GP, having a COPD related IP admission (any type) in the last 681 690 684 12 months 658 656 657 647 641 651 646 610 Number of 599 600 584 patients not 561 540 545 diagnosed with 519 COPD by GP, 499 479 479 having a COPD 461 470 related IP admission (any type) in the last 12 months Total number of COPD related IP 479 453 632 608 562 534 483 464 664 623 618 617 604 583 562 543 528 514 503 412 398 393 admissions (any 300 type) in the last 12 months 1/1/2010 1/3/2010 1/4/2010 1/6/2010 1/9/2010 1/3/2011 1/4/2011 2/7/2011 4/8/2011 1/9/2011 1/2/2012 3/3/2012 8/4/2012 9/6/2012 1/11/2010 31/1/2011 16/6/2011 8/10/2011 21/1/2012 19/5/2012 19/11/2011 11/12/2011 COPD admissions showing sub analysis by patients known and not known to GP with a diagnosis of COPD within : Barking and Dagenham
  21. 21. Intervention stage 2 Patient empowerment Promote improvement through patients Send each COPD patient a score card containing a report on the core primary care interventions VIDEO
  22. 22. Learning• Define Patient Risk factors “Quality Care”• Measure Quality Care• Multi Level Educational Intervention• Data reliability critical• Massive Practice Variation• Huge Learning need• Work from within• You can make a difference (and quickly)

×