The Government believes that NHS clinicians will be better equipped to identify patients with long term conditions who are most at risk of unplanned and unnecessary hospital admissions, thanks to a model recently launched in the NHS.
In addition, as it uses a combination of primary and secondary care data sources, the model can also categorise people with long term conditions according to their risk of hospital admission, enabling organisations to implement different interventions and care pathways to meet these needs. The Combined Model is expected to assist community matrons and other case managers, who are responsible for planning and co-ordinating patient care, and to facilitate a joined up approach from integrated health and social care teams.
Health Minister Rosie Winterton said: “Our population is getting older and more of us are living with an illness or condition which means huge increases in demand on health and social care services. Many PCTs are adopting case management approaches as a means of ensuring the most vulnerable people receive fully joined up health and social care and have person centred care planning.”
The King’s Fund and their partners, Health Dialog and New York University, were commissioned by the Department and the Strategic Health Authorities in 2005 to develop a number of techniques to accurately predict the future frequent users of hospital services. The first tool, the Patients at Risk of Re-hospitalisation (PARR) was launched last year, and is actively being used by many PCTs.
The Combined Model builds on learning from PARR but draws on a much larger and richer data source. Pilot sites have shown the Combined Model to be an effective tool for delivering better care for people with long termconditions and helping to reach and sustain the target reductions in emergency bed days.
King’s Fund chief executive Niall Dickson said: “Providing better care for people with long-termconditions is one of the great challenges in modern healthcare. This new model will armhealth care professionals with the information they need to target patients who face a much greater risk of ending up in hospital if their conditions are not managed effectively in the community.
“Previous techniques only allowed us to identify patients who had already been admitted to hospital on at least one occasion. However, this model allows us to go beyond this group to identify and provide better care for the vast numbers of people whose conditions are not yet at this critical stage. Helping these patients with good disease management programmes, or supporting them to self-manage, should have a great impact on their daily lives and prevent unnecessary hospital admissions.
Geraint Lewis, Specialist Registrar at Croydon PCT where the Combined Model was tested, commented: “The Combined Model has transformed the way we look after people in Croydon who have complex medical and social needs. By allowing us to identify individuals before they become acutely unwell, our clinicians can offer proactive, rather than reactive care.”
