The Risk Stratification tool within Aristotle Xi has helped Wolverhampton CCG reduce A&E attendances and emergency admissions by identifying high-risk patients, enabling proactive care and improving integrated community health outcomes.

Background

With growing demand and increasing cost pressures, most CCGs across NHS Midlands and Lancashire’s (NHS ML) footprint were seeking to reduce the numbers of attendances at A&E, the numbers of avoidable emergency admissions and readmissions and inappropriate lengths of stay in hospital. CCGs needed to target interventions at those most at risk of attending A&E and being admitted to hospital, with the intention of reducing cost and improving outcomes.

Action

On Wolverhampton CCG’s patch, we met with 46 GPs and introduced them to the Risk Stratification toolset within Aristotle Xi. This is our business intelligence system which provides patient risk and patient activity data, enabling all practice staff to see their patients’ A&E attendances, emergency and elective admissions and Urgent Care Centre and outpatient attendances.

The Risk Stratification solution, at no additional cost to practices:

•Uses the Combined Predictive Model (CPM) algorithm to rank patients based on recent events (activity and frequency), chronic conditions and ICD10 diagnostic codes

•Exports data for the top 2% DES (Directed Enhanced Service) and imports the NHS numbers into the practice’s system (EMIS, Systm One, Vision) earmarking these patients as high risk

•Identifies potential case management patients for community matrons who could monitor them prior to MDTs (Multidisciplinary Teams).

Impact

•Approximately 200 patients that weren’t previously on the caseload of community matrons were identified. 

•Patients were invited to attend a review meeting with the GP which led to a reduction in A&E attendance and emergency inpatient admissions. 

•Alternatively, the patient review resulted in changed care or medication and got them onto the community matron’s caseload.

•Patient data was collected in a central database on the hospital’s Patient Administration System (PAS). This improved quality of care bringing GPs closer to the community matrons to achieve enhanced integrated community care.  

•Complex cases identified were taken to the Community Neighbourhood MDT meetings for multi-professional input to the patient’s health and wellbeing. 

•Overall the project led to better care for patients with long-term or life-limiting conditions.  

•Aristotle Xi was praised for identifying the medium to high risk patients of which GPs are not necessarily aware. 

•GPs reported the system was easy to use and complimented the speed of report retrieval/querying.  

•Some of the practices acknowledged how easy it is to collate evidence for when the practice is assessed.

Key reporting features

•Set criteria to create cohorts of patients for review based on: chronic conditions, pre-defined reports (Top 2% DES, Case Management Top 0.5% or Disease Management (0.5-5%)), age (18 to 120 years), and other Quality and Outcomes Framework (QOF) conditions used.

•Easily export and print information in a variety of formats capturing the full dashboard.

•Data is usually reported six to eight weeks after month-end and is refreshed monthly.

For more information

For more information and to learn how we can help your organisation, please contact us.