Improving outcomes for vulnerable residents in Lancashire and South Cumbria
Our Business Intelligence team’s data-driven approach led to: improved care access, lowered acute service demand, and empowered patients, making a positive difference for vulnerable residents in Lancashire and South Cumbria.
NHS Midlands and Lancashire CSU (MLCSU) was approached by Lancashire and South Cumbria Integrated Care Board to improve outcomes for the most vulnerable residents during the winter season. Sixty-eight per cent of the targeted cohort continued to experience unmet needs leading to inadequate support or referrals.
To achieve the project’s goals, we used our established infrastructure, specialised skills, expertise, and vision to produce actionable insights. We focused on the prevalence of respiratory conditions in Central Lancashire by using health inequalities and population health management segmentation tools to create a target cohort. Responding to national direction, Core20PLUS5, the project team collaborated with service leads, analysed local data flows, and employed geographical views of data to benchmark across geographies.
The Winter Respiratory High-Risk project aimed to reduce the demand for acute services and admissions and identify unmet needs and address them. To identify wider determinants, the Business Intelligence team used Acorn Geo-segmentation tools which helped improve access, experience, and outcomes for the targeted cohort, and led to disease and medication reviews, immunisation offers and social prescribing.
MLCSU established a dedicated help desk and provided training support for staff, ensuring data quality through data warehouse processes, and linking primary and secondary care data. The team was able to capture additional patient activities, such as flu vaccinations, and update patient records with a long-term condition diagnosis, enabling referrals to support services.
The Winter Respiratory High-Risk Project identified that fifty-two per cent of the targeted cohort had multiple support needs, emphasising the importance of addressing unmet needs. We also shared best practices from other areas and applied lessons learned to refine the process, leading to an improved experience and better outcomes for the targeted cohort. The client was provided secure access to Information Governance compliant patient data, ensuring data protection and privacy. This initiative played an essential role in reducing the demand for secondary care and lowering morbidity rates, empowering patients to manage their health conditions more effectively.
Simultaneously, the average proficiency of individuals in managing their own health and well-being – measured through a Level 3 status – underwent a remarkable transformation. Starting from an initial low-end Level 2 status, which signifies individuals struggling to understand their role in healthcare, we successfully elevated their perception to an empowered Level 3 status. This designation signifies individuals who recognise their integral role in their care journey and possess the knowledge to proactively engage in self-care.
“The MLCSU Business Intelligence Team were an integral part of our respiratory work. The team made time to work with us to fully understand the project requirements and desired outcomes. This allowed the team to make suggestions relating to selection of appropriate cohort criteria, to ensure the project targeted those most vulnerable and most at risk. One project requirement was to enable members of the Primary Care Network to generate patient cohort lists – The BI Team were able to streamline this process by creating pre-set filters and guidance documents, ensuring buy-in from the Primary Care Network.”
Naomi Coldham, NHS Lancashire & South Cumbria Integrated Care Board
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