A new computer tool that helps clinicians to identify patients with long term conditions who are most at risk of unplanned and unnecessary hospital admissions has been launched by the Department of Health.
The Combined Predictive Model has been developed by the King’s Fund, Health Dialog and New York University. It uses accident and emergency, inpatient, outpatient and GP data sources to identify future frequent users of hospital services beforehand, allowing for earlier intervention.
The aim of the tool is to cut emergency admissions by allowing authorised staff to intervene before the situation becomes critical.
A Department of Health spokesperson told E-Health Insider: “The Combined Model has transformed the way we look after people who have complex medical and social needs. By allowing staff to identify individuals before they become acutely unwell, clinicians can offer proactive, rather than reactive care.”
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.”
Using the data, 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.
King’s Fund, Health Dialog and New York University were commissioned to develop a number of techniques to accurately predict the future frequent users of hospital services in 2005.
Last year, they launched the Patients at Risk of Re-hospitalisation (PARR) tool, which is actively used by many PCTs.
“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,” Winterton said.
The Combined Model builds on learning from PARR but offers acute trust clinicians a much larger data source to help them deliver better care for patients with long-term conditions.
King’s Fund chief executive, Niall Dickson, said: “Providing better care for people with long-term conditions is one of the great challenges in modern healthcare. This new model will arm health 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.”
The tool was released as the NHS released figures showing the Long Term Conditions Public Service Agreement target had been met early.
Winterton said: “I am very pleased that there has been a reduction in emergency bed days in 2005/06 of 5.4 per cent – some 1.7 million bed days – compared to the 2003/04 baseline year. This means that the national target of 5 per cent by 2008 has been met early. Though this is a significant achievement, continued efforts and reform are vital if we are to maintain these important improvements in patients care and sustain the bed day reductions into the future.”
Dickson added: “For millions of people with long-term conditions this could be the start of a new and exciting era. This more sophisticated approach will be crucial not only to provide better care but also to make better use of NHS resources.”
The Combined Model is available from the King’s Fund website or the NHS Networks website.