As part of their winter planning strategy, Gloucestershire CCG engaged Sollis to help build case finding reports to identify patient cohorts at high risk of attending A&E. One report identified older, higher risk patients with Chronic Obstructive Pulmonary Disease (COPD). Another report identified older patients with Left Ventricular Systolic Dysfunction (LVSD). Identifying these cohorts helped the CCG to plan interventions with the aim of easing pressure on A&E departments.
Using Sollis the Clarity Multi-practice Case Management application, Sollis helped the CCG to develop a report that identified all patients with the following criteria:
- Aged 65 and over,
- who live alone or have an elderly carer,
- who have a COPD diagnosis,
- who have had a spell in hospital in the last 12 months.
Patients were grouped into five-year age-band cohorts, from 65-69 to 90-94 and then 95 and over. The CCG grouped these patient cohorts into its seven member localities, which contain between 4 and 19 GP practices. Each GP practice could then access its own patient list with a single click in Clarity Patients, enabling them to identify the patients for review or intervention.
A second report was built to identify patients aged 80 and over who have been diagnosed with Left Ventricular Systolic Dysfunction (LVSD). These patients were grouped by number of diagnosed co‑morbidities in addition to LVSD: 0, 1, 2 and 3 or more. The patients’ co‑morbidities were also identified in the report. As with the COPD report the patient lists were grouped by locality and made available to each GP practice.
Sollis the Clarity with the integrated Johns Hopkins Adjusted Clinical Groups® (ACG®) System is helping commissioners and clinicians to deliver better care and outcomes through advanced population health analytics.
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