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Enabling a population health management approach to improve end of life care
Our population health analytics platform, Aristotle Xi, has helped a group of Leicestershire general practices to offer the right support to a greater number of patients nearing the end of their life.
Willows Health is a group of seven Leicestershire practices with over 43,000 patients and is part of the Aegis Primary Care Network. The GPs’ proactive approach towards population health management (PHM) includes identifying patients potentially nearing the end of their life to ensure they are given appropriate care and support. However, they have struggled to identify this population in a comprehensive manner. An audit carried out by the team identified that half of patients who had died in the previous six months did not have a care plan.
MLCSU’s population health analytics platform, Aristotle Xi, gives users rapid access to an online suite of business intelligence tools and reports to support PHM. It is being used to give the clinicians a Mortality Risk Score (MRS) – a new algorithm generated from outputs of the Johns Hopkins Adjusted Clinical Group (ACG®) System. This enabled them to identify a large number of patients who had not previously been included on the palliative care register.
Once the list was created, it was given to members of the clinical team so they could undertake a review of patients on the list to determine whether they would benefit from a palliative care plan and to determine the urgency of such a process.
This innovative work has enhanced and supported Willows Health’s care planning work with palliative care patients and enabled them to provide patient-centred reviews and end-of-life care plans for those with higher levels of risk. These have helped reduce hospital attendances and length of stays.
Aristotle Xi and the ACG System support the group’s clinical programme, enabling proactive assessments, enhancing the quality and experience of care through optimisation of long-term conditions, undertaking medication reviews, signposting to additional support systems and exploration of patients’ care preferences and best interests in this context.
Willows Health GPs are now able to offer the right support to a greater number of patients who are nearing the end of their life.
The tool is fantastic – it lets us look at how we can approach patient care and look at the overall coordination of care. The 30 or 40 patients that were identified have gone on to have care plans created, which means they will have had a more comprehensive and up-to-date clinical assessment of their needs and had the opportunity to discuss their preferences for care near the end of their life; all this makes for a more patient-centred approach near the end of life and reduces unnecessary activity within the hospital, which is a huge benefit. The whole process has been so useful and we are exploring new ways to improve population health and reduce costs.
Dr Vinay Gupta, GP partner, Willows Health
We are now able to offer the right support to a greater number of patients who are nearing the end of their life. On reviewing some clinical outcomes, we found a correlation with fewer hospital attendances for those patients who had undergone such proactive clinical assessments and care planning. Where patients were in hospital, they spent fewer days in hospital when they had care plans in place (40-50% less). We are now intervening with the right set of people, a lot of whom didn’t have care plans. This is when the risk score has a lot of value. The tool helps us optimise case-finding to deliver a really patient-centred approach.
Dr Richard Wong, Consultant Geriatrician, University Hospitals of Leicester NHS Trust.
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