NHS Arden Commissioning Support Unit has created a risk stratification tool to support GPs managing high-risk patients.
The CSU developed the system in order to enable GPs to proactively manage patients at risk for preventable hospital admission or A&E visits.
The web-based tool uses primary and secondary care data, as well as real-time information on admissions, and the CSU has built a set of algorithms which let GPs identify and track the high-risk patients.
It also informs practices if any of the patient registered with them have been admitted to hospital or attended A&E in the last 24 hours.
The tool is now in use at 200 GP practices across Coventry, Rugby, Warwickshire and Worcestershire.
Dr Alia Fahmy, one of the GPs using the system, has used it to develop personalised care plans.
“Risk stratification has been promoted to help reduce hospital admissions, but as an added advantage patients feel reassured that if emergency help from out of hours services is needed.
"The provider has a summary of the patient’s medical history, medication and recent blood tests results,” she said.
“As a practice it has made us more aware of the importance of establishing a better knowledge of individual patients’ end of life wishes, for example.
“We now recognise the importance of asking where a patient's preferred place of care is, as most patients wish to stay in the comfort of their own home.”
The risk stratification tool, which is available in Ventris, the CSU’s business intelligence system, analyses more than 80 variables such as demographics, previous hospital attendance, medicines and known conditions.
Adam Powell, business intelligence developments lead at the CSU said that after listening to what GPs needed, the tool was built based on their requirements.
“The enhanced functionality of Ventris will allow quick and easy identification of those at risk of admission in the coming twelve months and will provide the intelligence required for proactive case management,” said Powell.