The challenge
A requirement was identified in York Place within Humber and North Yorkshire ICB to create a proactive social prescribing model for targeting cohorts of patients who could benefit targeted interventions. York Place received funding from the ICBs personalised care team to improve and deliver personalised care and this was invested into the project.
With the current cost of living crisis and upcoming winter pressures, it was agreed that the social prescriber would deliver intensive interventions targeted at a specific, complex cohort of patients, particularly focusing on areas of deprivation across York city.
Our response:
The York Place team in Humber and North Yorkshire ICB engaged with RAIDR to create a SmartLink to identify patients living with respiratory conditions in IMD deciles 1-5 who were at high or very high risk of hospital admission in the next 12 months, as predicted by the combined predictive model (CPM) that is built in to RAIDR’s Primary Care dashboard.
Other platforms had been considered to assist with the project, however RAIDR was the only source that provided the data required when considering areas of deprivation at IMD level to focus on health inequalities and combining primary and secondary care. The built in predictive model was also key to creating the required cohort.
The SmartLink was circulated to BI leads and GP Practices across the region to create lists of patients that could be referred proactively to social prescribers. After several months and regular training sessions delivered by the RAIDR team, the nominated staff are now fully engaged with the platform and are self-sufficient when running the searches.
Defined patient lists are now available each month for the social prescribing lead to easily access and assess.
Outcomes
- The initial phase was to test that the numbers provided via the RAIDR dashboard were consistent with those being pulled locally and fortunately, this was the case. This then led into the next step, which was to create specific cohorts of patients living in certain areas of deprivation who were highlighted as being potentially at risk of hospital admission. The patient lists were then passed on to the proactive social prescriber to see what could be done in terms of improving outcomes and delivering more personalised care to these individuals.
- Through initial engagement with these individuals it became evident that a key voluntary service supporting people with respiratory conditions had recently ended. Re-establishing this service is now being explored as part of this project.
- The linked data presented by RAIDR has saved valuable resources within the ICB and has facilitated a multidisciplinary approach to recovering services, improving access and exploring more effective patient pathways.
- The proactive social prescriber is in the process of carrying out intensive, targeted interventions with those identified and have an established process to continue this work.
“No other platform could provide the information required to carry out this programme with the focus on health inequalities that we needed. RAIDR helped to deliver a proactive social prescribing model where individuals could be proactively identified using a shared dataset to meet their needs early, rather than wait for patients to present with further issues or have their existing conditions exacerbate. Relationships between York Place and General Practice have strengthened as a result of working together to achieve a shared goal.”