The previous RST was difficult
to use, did not collect data from multiple sources and had limited capacity to
inform clinicians why the patient was high-risk. We learnt that what GPs wanted
was an information management tool that is simple to learn, quick to use, and
capable of returning high-quality, reliable and useful data.
Using the new tool, GPs,
clinicians and community matrons can now understand their patient population
better and identify those at risk of hospital admission in just one click of a
button. Once identified, enough patient information is available for the
clinician to plan appropriate care pathways and monitor progress. So this
system not only improves patient outcomes, it helps reduce the significant
costs associated with unplanned hospital admission.
The new RST also supports
Somerset CCG’s QIPP initiatives. For example, the tool was used to identify
high-risk patients based on previous hospital admission who might benefit from
Tele-health units. The pilot was a
success, reducing these patients’ incidence of hospital admission by 30%.
Around 98% of GPs in Somerset
are using risk stratification regularly to identify and monitor high-risk
patients. Risk stratification is also identifying incorrect use of secondary
care services and supporting practice management. Our work has given Somerset a
strong foundation for understanding integrated health and social care data.
Subsequently, we worked with Sir
John Oldham, in his role as national clinical lead for QIPP, to demonstrate the
potential for risk stratification within the health and social care system at
events around the country. We also worked with United Health on the development
of new risk stratification algorithms.