Wandsworth Clinical Commissioning Group (CCG) in South London plans, commissions and monitors health services for over 370,000 registered patients across 43 GP practices. These services include non-emergency and emergency hospital care, mental health and learning disability, community health care and rehabilitation care. Working with a broad spectrum of local care providers and partners, Wandsworth CCG is improving patient experiences and outcomes, reducing inequalities in care provision and working to ensure equal access to healthcare services for patients.
One of the CCG’s key initiatives is aimed at changing how patients with long-term conditions receive care. The Planning All Care Together (PACT) programme is designed so that patients are able to manage their conditions more independently after illness or injury. The vision is that community health and adult social care services will work as one service with the patient having to face fewer steps as they move across health and care services. PACT is designed to deliver a better coordinated plan of care that is individually tailored to patients’ requirements.
PACT aims to revolutionise how patients in Wandsworth with long-term conditions are cared for. It targets the triple aim of better patient outcomes, better patient experience and reduced cost. A fundamental objective of the initiative is its redesign of community health and adult social care services to work side-by-side, helping patients to remain within their own homes and reducing hospital visits.
How Sollis Helped
One of the keys to the successful implementation of PACT has been the innovative use of information technology to identify patients most in need of intervention and to evaluate the impact of the programme. Sollis was one of a number of partners Wandsworth CCG chose to help them implement the PACT initiative. The PACT programme uses Sollis Clarity and the Johns Hopkins HealthCare Adjusted Clinical Groups® (ACG®) System – alongside clinical judgement – to identify the at-risk patient cohorts for different levels of treatment:
- Patients identified as ‘at risk’ are provided with a 10 minute prevention consultation with a nurse, and a further 20 minute prevention consultation with a GP.
- Higher risk patients, and who are diagnosed with sickle cell, receive a pre- care plan assessment with a nurse or health care assistant, averaging 20 minutes. Two to three days later the patient is sent the results from this assessment. After two weeks the patient attends a care plan consultation with a GP, averaging 40 minutes. A subset of higher risk patients in this cohort require only the 40 minute GP consultation.
A third cohort identified by the PACT initiative is housebound patients and those with learning difficulties, who are reviewed by a GP.
The risk and population profiling analysis provided by Sollis Clarity and the ACG System identifies these ‘at risk’ patients and provides the CCG with the insights to help put in place the care plans and services where they are most needed.
The PACT programme is designed so that patients are able to manage their conditions more independently after illness or injury.
At the start of the project, the CCG worked closely with GE Healthcare Finnamore (GEHCF) to develop an evaluation of the Out of Hospital programme. GEHCF reviewed the evidence base for impact of similar schemes to identify a number of indicators to show patient benefit. This led to an evaluation model being built which draws on anonymised data sets to monitor the combined impact of schemes.
Working with GEHCF, Sollis set up the anonymised data extraction for Wandsworth CCG. Using costed primary and secondary care data, this initial analysis helped enable PACT care programmes to be properly selected, defined and planned.
Sollis also worked with the CCG to define a report showing each practice’s utilisation of the new programmes, to ensure they were being appropriately offered to patients across the population.
Sollis worked with the local Commissioning Support Unit and GEHCF to deliver a detailed, IG-compliant monitoring report, enabling the CCG to review the PACT programme operation and begin assessing its benefits. This required detailed analysis of care activity and costs, clinical codes present in GP records and data validation to ensure data quality.
The monitoring analysis is fully automated and delivered via a secure portal in Sollis Clarity, enabling the CCG to monitor PACT programmes with no additional support required from Sollis.
The PACT programme has been operating successfully for several years and is being extended to include those patients also in need of high-impact multi-disciplinary team support. The programme illustrates how high quality data and analytics can help deliver insight that supports service transformation and so provide better patient outcomes and a better patient experience.
The true value of any business intelligence / health analytics solution is measured in the contribution it makes to improvements in health outcomes and the wider health and social care system. In commissioning terms the value exists in the quality of decisions taken by CCGs and the service transformation achieved. Wandsworth CCG and its partners have demonstrated how the application of innovative digital health solutions – in this case Sollis Clarity with integrated ACG System – can assist in the development of equally innovative new care models. The PACT programme is a shining example of how high quality data and analytics can support service transformation and help deliver better patient outcomes and a better patient experience.
Related content: Planning all Care Together (PACT)