The Business Intelligence team recently supported the Birmingham Cross City Clinical Commissioning Group to trial a pilot scheme using detailed information on patients admitted to hospital to plan coordinated care and significantly reduce readmissions and in-patient bed days.
The team developed the Urgent Care Dashboard which brought together daily patient data enabling information on people admitted to be accessed first thing every morning.
Community care coordinators with clinical knowledge from three practices, practice managers and the CCG’s GP leads for urgent care were recruited to the scheme and trained in using the dashboard.
Using the system allowed reviewing emergency admission and discharge data at 9.30am each day enabling them to use patients’ NHS numbers via a separate system to see why they were admitted and the treatment received. The care coordinators then worked in collaboration with Good Hope Hospital’s discharge teams, next of kin and, where necessary, social services and community care teams, to plan for patients’ discharge.
The Urgent Care Dashboard provided more timely information about patients admitted into hospital, advising the practices in some cases up to three days before notification via the discharge letters. This provided more immediate and timely involvement and action planning with the acute provider.
Feedback on the pilot suggested 17% of potential admissions were avoided by early interventions during February alone. Bed days were reduced as a result of identifying current emergency admissions within 24 hours of admission and working in co-ordination with the hospital discharge teams to implement suitable care plans sooner within a community or home setting, reducing potential bed blocking.
By identifying the patients using the Urgent Care Dashboard and identifying the discharge date, care coordinators were able to assess patients sooner than waiting for the discharge letter, meaning palliative care assessment and interventions were implemented sooner, leading to improved patient care and treatment for the patients.