In an HSJ article published last week, Samantha Jones, director of New Care Models Programme, discussed the value of prevention to the new care model vanguards.
‘Prevention’ in some cases simply means preventing an unnecessary admission to hospital, while in others it refers to the proactive monitoring of the whole health population, where the purpose is to identify the groups most at risk of ill health.
New Care Models and Prevention, published by the NHS Confederation last month, illustrates the value of pursuing the prevention of illness. The paper considers the individual approach taken by five of the vanguards: West Wakefield Health and Wellbeing; Sutton Homes of Care; Connecting Care – Wakefield District; Solihull Together for Better Lives; and All Together Better Sunderland.
The case studies demonstrate the importance of having a holistic understanding of the health needs of the local population, including the use of some risk stratification. As considered by NHS England, risk stratification involves the early identification of high risk and high cost individuals, to engage and support them with the purpose of improving their health outcomes and experiences.
All Together Better Sunderland:
In Sunderland, evidence shows that 3% of patients account for 50% of NHS costs, with the next 12% accounting for 36% of costs. Central to All Together Better’s new model for out-of-hospital services has been gaining a better understanding of the population’s health needs through risk stratification.
To date, All Together Better has focussed on the top 1%, with new community integrated teams working to wrap services around these people as holistic support. All Together Better have experienced early success in a reduction in emergency admissions to hospital for people aged over 65.
We believe a referral management service or single-point of access is critical in delivering more patient centric proactive care. Risk scores or other factors can be incorporated into our triage engine to ensure that the right patient is referred to the right destination first time around. psHEALTH’s Referral Manager can also deliver benefits to urgent care centres or case management teams.
Joshua Murray, Partnership Manager