The Clinical Commissioning Group (CCG) of Vale of York, UK, uses predictive analysis to identify patients at risk of unplanned hospital care.
The system, developed by Health Navigator, uses predictive algorithms, based on learning 30,000 patients over 10 years, that use patient health information to assign each patient a risk score.
Scores are then manually checked by nurses to decide which patients to recruit for the Navigator’s Proactive Health Coaching service, a mix of telephone contacts and in-person interventions to help patients better manage their condition.
The project was commissioned by the Vale of York GCC and aims to address the NHS’s increasing demand for urgent and emergency care services.
A randomized clinical trial (RCT) at York Teaching Hospital showed a 36% reduction in A&E attendances for patients supported by health coaching
The study also demonstrated a 30% reduction in unplanned hospital admissions and some 25% lower planned admissions for the same Vale of York CCG patients.
Based on the results, the Vale of York GCC extended the contract to 1,800 patients.
Fiona Bell, the CCG’s lead officer for primary care, said: “High emergency admissions are a system problem, not just the responsibility of secondary care. A lot of people go to A&E if they are feeling anxious about their health or they need reassurance”.
“We needed to find a way to support these patients to help them understand their conditions better, make life changes which will improve their health and know which services to access when they need support.”
“From the local RCT, we found that 55% of patients felt much more engaged with their care, whilst 84% of people reported improved quality of life and have more confidence in managing their conditions. These results are really impressive and have a huge impact on patients’ everyday lives.”
There are plans for Vale of York to become the first CCG to extend this type of service into primary care to alleviate the increasing demand for GP appointments, which Bell described as a “really exciting next step”.
She added: “If we can replicate the results from the RCT trial on a larger scale then we are confident that we will have a significant and positive impact on reducing growth in A&E attendances and non-elective admissions”.
Joachim Werr, CEO of Health Navigator, said: “We know that 1% of the UK population represents 50% of days of inappropriate hospitalization, so there is huge potential for new care models like this, based on scientific evidence and real patient benefits, to reduce avoidable hospitalizations and improve system performance”.
Digital-health 