Customer stories
Developing a more holistic approach to falls prevention
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Although falls and fragility fractures are more common in older people, they are often preventable and should not be seen as inevitable. This is the principle driving a new, proactive care approach supporting people in Suffolk.
Overview
Detailed analysis of linked datasets across Suffolk and North East Essex (SNEE) ICB found that falls were the primary driver of high-cost service use across many parts of the ICS. This led to the development of a new, holistic approach to identifying, assessing and helping people at risk of falls, delivered by an integrated neighbourhood team (INT) in Woodbridge.
Approach
Using Optum’s PHM Pathfinder Analytics, the SNEE team were able to gain a deeper understanding of the factors contributing to falls, as well as a clearer view of the impact this was having on service usage and costs across the system.
Their analysis compared people who had experienced a recent fall with those who had not. It looked at their key health conditions and risk factors, their average number of contacts with services, and the average costs per person per year by service used. Population projections were also added to forecast future falls activity and cost.
The results identified a particularly high rate of falls in the Woodbridge area, leading to the development of the Woodbridge Holistic Assessment Team (WHAT) – an integrated team of professionals who provide early intervention support for first fallers, those who have experienced stumbles or near-misses, and those who are anxious about falling.
What is the PHM Pathfinder Analytics?
PHM Pathfinder Analytics is an analytics tool developed by Optum on behalf of SNEE to help them analyse their linked dataset. It creates dashboards that visualise data, allowing teams to explore cost segmentation and risk stratification, impactability modelling and gaps in care, and patient-level theographs showing individual patient pathways.
Key numbers
10,000+ people over 65 have had a fall in the last two years
£65 million cost for services after falls
£1.9 million projected savings if falls admissions drop by 10%
Impact generated
Supporting high quality, integrated neighbourhood services
The WHAT offers tailored health and care advice, support and guidance to people identified as being at risk of falls. The service provides faster, more proactive access to care and reduces the need for people to attend multiple appointments over several days, thereby minimising the risk of further falls.
Stimulating new partnerships and opportunities to innovate and scale
The experience in Woodbridge has opened new avenues for deeper partnership working and innovation. One example is the development of the Zibrio Stability Home Scale, a new evidence-based tool that can be used to assess falls risk, currently awaiting regulatory approval. Similarly, the ICB is working with Suffolk Fire and Rescue on how it can include falls prevention advice and information routinely during fire safety visits across the region.
Inspiring greater use of data-driven approaches across the system
The momentum created by the WHAT project has also inspired the greater use of population health management approaches across the ICS, with new projects underway centred on complex patients and hypertension – both of which use a similar integrated neighbourhood model bringing together clinicians, INTs, voluntary and community sector organisations, and community champions.
What has been achieved in Woodbridge is a good example of a highly cost-effective, community-based, multi-disciplinary approach delivered within a single setting. It shows that having access to linked data, and the insights it provides, can help us all work in a more integrated, intelligence-led way to improve outcomes for our populations. Our partnership with Optum has been invaluable in inspiring these new ways of working.”