Supporting new models of care and preventative treatment to help vulnerable patients

Vulnerable people often move around well-meaning but segregated sectors of care that can fail to connect and treat all of their health needs. It’s something that needs to be tackled now – not only are there 1.85 million adults in contact with mental health services, the number of those aged 85 and over is set to increase too, by over 122% in the next 20 years.

New models of care can work alongside preventative treatment to combat these pressing patient needs. By shifting treatment toward a healthcare community that allows providers across sectors to work in unison – all while helping to head off more complex health concerns before they come to fruition – organisations can help to alleviate the pressures they face while ensuring patients are placed at the heart of connected care.

Halving A&E admissions for frail and elderly patients

It’s often the case that vulnerable and frail patients will end up in hospitals requiring unplanned treatment. This places pressure on not just overburdened secondary care organisations, but on patients too, who can find that their stay in hospital is prolonged if they need to wait for additional support to be put in place. That’s why we’ve seen the formation of urgent and emergency care and multispecialty community provider (MCP) vanguards, which focus on ways to reduce the strain on emergency departments and provide integrated care outside of hospitals.

Essential to making new models of care like these a success is access to detailed information from across organisations, so that clinicians can make better informed and more proactive decisions.

The Oxford Terrace and Rawling Road Medical Group (OTMG-RR) have been able to cut A&E attendances by 54% thanks to this approach. With personalised care planning and shared records in EMIS Web, GPs were able to identify 2,500 patients who were at risk of hospital admission.

“Making sure all those involved in an individual’s treatment are aware of progress in real time, through a shared record is essential.”

Sheinaz Stansfield, practice manager

As practice manager Sheinaz Stansfield explains, “our primary care navigators and healthcare assistants will call at-risk patients and identify health and social factors that could affect their health.” With this information, “the broader team are able to suggest action – including the best people to take action – to prevent the situation from escalating.”

Intelligent information for preventative care

Since care providers have a wealth of information at their hands, it makes sense to make use of this to identify developing health concerns and those most at risk. A secure way to do this is to use analytical tools and business intelligence, which can give important insight into your population’s health and wellbeing through the data you already have.

This can even be done within your clinical system. Built within EMIS Web, the electronic frailty index is a protocol that scores patients aged 60 or over against specific criteria for moderate or severe frailty. It automatically alerts clinicians if patients meet these criteria, so that they can easily determine whether they need to intervene. This can run alongside other solutions that can help you to identify vulnerable patients at all ages, like Risk Stratification, which integrates with EMIS Web to easily identify the top 2% of at-risk patients.

Understanding patients’ health and needs can be done across multiple providers too, to help organisations involved in new models of care and initiatives to monitor the success of their efforts. An intelligence platform like EMIS Health Analytics uses reports and dashboards to detail information on things like long-term conditions so that outcomes, productivity and activities can be monitored. CCGs, GP federations and Health Boards can also report on patients in real-time with Enterprise Search and Reports, so that their practices can better help those who are vulnerable.

It’s a system that South Warwickshire GP Federation (SWGP) are using to transform the care they provide to their elderly patients, as they can now run reports for their 31 practices to identify those who need extra support. The practices then work with Age UK Warwickshire to review patients and improve their care – which has already helped to reduce A&E and non-elective admission rates.

Unplanned admissions outside of hospitals

While there are ways to help improve patients’ long-term wellbeing, there’s always going to be patients who present for unscheduled care. The key for these patients – and integral to new models of care – is to make sure that they’re being treated in the right place.

From walk-in centres to minor injury units, there are a range of unscheduled care organisations that can be more appropriate for patients than A&E departments. Like with other organisations, it’s vital that clinicians in these settings have access to shared care information – while it’s also important that they can feed back to other providers. 

It’s something that doesn’t have to involve complex ways of working since it can be done from within your clinical system, like with Patient Tracking in EMIS Web. An additional module, it helps clinicians to track and effectively manage patients throughout their time in care so they can avoid breaching NHS England’s four-hour target, and includes access to a patient’s Summary Care Record (SCR). It also allows clinicians to work closer as a team, with tasks and outstanding actions that can be shared across departments and organisations.

Moving care to the community

New models of care place an increasing focus on ensuring that care, where appropriate, can be delivered in the community. For vulnerable and frail patients, that means they can be treated in their own residences.

This is something that can make a big difference to patients’ mental health and overall wellbeing, particularly since it can often be difficult for them to attend healthcare premises. Community clinicians, where appropriate, will also make visits to the same patients repeatedly, which helps both them – since they can build up a more detailed picture of a patient’s health – and patients, who can find it comforting to be cared for by the same clinician.

Community clinicians can be faced with barriers though, since the nature of their roles means that they don’t have access to the same level of information site-based clinicians do. That’s why providing them with mobile technology can make a big difference

It’s something that more than 300 clinicians at Bromley Health CIC have made use of with EMIS Mobile on iPads. Used by the admission avoidance team, it’s helping nurses by giving them access to real-time patient records at the point of care.

“I have found the iPad so much easier to be able to access patient records and note down new consultations. I can respond to patients who need urgent care more quickly.”

Wendy Silvester, advanced nurse practitioner for medical rapid response team.

Supporting new models of care and preventative treatment

New models of care and preventative treatment can really help to change the health of vulnerable and elderly patients for the better. But in order to achieve such an ambitious evolution of care, providers need the right support.

Systems and solutions can be the key to this. By shifting to proactive rather than reactive care, and helping providers to work together as a community, technology can act as the backbone to achieving improved health for those who need it most.

To find out more about how we can help, email or call 0330 024 1268.

This article was written by Ian Bailey, district nurse, Queen’s Nurse and senior clinical informatics consultant for EMIS Health.