Customer story | Proactive care pays for itself

A pilot led by Trent primary care network (PCN) applied PHM Pathfinder Analytics to identify patients who are frequently using emergency services. Funded through Lincolnshire’s Health Inequalities programme, the service targeted vulnerable groups facing multiple challenges due to poverty, co-morbidities, substance misuse, unhealthy lifestyles, homelessness, mental health issues, relationship breakdowns and physical disabilities. Using defined criteria, analysts provided the local team with a monthly report of locally registered patients who have used Accident & Emergency (A&E) and other health services most frequently over the last 12 months. These patients were then contacted by a link worker and assessed to understand the wider factors that may be causing them to attend services. After this, if deemed relevant the patient was referred to other clinical and non-clinical services, including mental health, addiction clinics, social prescribing and voluntary or community-based enterprises.

Target group

People over 18 years old that have attended A&E seven or more times in the last 12 months and are not on an end-of-life pathway.

Intervention

The High Intensity Use (HIU) services are focused on supporting people who use a significant amount of urgent and emergency care resources compared to the average population.1

This service, costing £70K annually, provides flexible, non-clinical support through two dedicated HIU leads. The HIU leads focus on the holistic needs of individuals in their preferred settings, aiming to uncover the root causes of frequent emergency visits. By collaborating with key partner organisations, they co-create personalised care plans that emphasise asset-based recovery and align with the individual’s goals. The service engages the entire community, working with voluntary sector organisations, social prescribers, and the council to develop tailored support solutions that meet each person’s unique needs.

Results

A rigorous evaluation, using retrospective control group methodology, revealed that an annual investment of £80K in two link workers achieved a nearly 3:1 potential return on investment within 6 months. This relationship based intervention supported emergency admission avoidance worth £230K versus the control group. This sort of robust evaluation requires a linked data model to demonstrate the value and return on investment of the intervention across the whole integrated system.

Benefits after 6 months

Emergency admissions down 58%

A&E attendances down 41%

GP encounters down 4%

Mental health activity down 37%