East Lindsey Primary Care Network

Providing holistic, proactive, long-term care for high intensity users of primary care.

AT A GLANCE

CLEAR CHALLENGE

High intensity users taking up a disproportionate amount of GP and hospital time – over 12 months, 89% had attended ED between five and nine times

KEY CHANGES

A new multidisciplinary model of care providing proactive, holistic care and support for HIUs with a particular focus on patients with anxiety, depression and hypertension

FORECAST BENEFITS

Improvement in the overall wellbeing of HIUs and a reduction in GP appointments, ED attendances and emergency hospital admissions generating potential productivity savings of £112,773

THE CHALLENGE

East Lindsey PCN in Lincolnshire had 82 high intensity users (HIUs) – patients attending the ED more than five times in 12 months – among their 54,000 registered patients.

Although making up only 0.1% of their total patient population, they created five times more GP activity. They accounted for 11% of ED attendances – 89% attended between five and nine times in 12 months – and 5.2% of all emergency hospital admissions.

Levels of anxiety and depression (A&D) and hypertension were much higher among these patients than among the general population.

WHAT WE DID

Data for all HIUs was extracted from the PCN’s EMIS medical information system for a 12- month period from August 2020. This was compared with data for 37,228 patients who received care from the PCN during the same period. Initial analysis focussed on the demographic details, distribution and comorbidities of these patients. PCN staff were keen to use the data to gain a better understanding of patients with anxiety, depression and hypertension.

CLEAR RECOMMENDATIONS

A new HIU service was recommended consisting of assistant nurse practitioners, care coordinators and health and wellbeing coaches with administrative support. Together they would provide 23 hours of care per patient per year for 82 HIUs.

A bespoke matrix developed in partnership with Hyde PCN was used to assist in the development of the model of care, exploring the skills and roles needed and quantifying them in terms of the number of hours required to deliver each element of care. This also included forecast outcomes and impact.

The new HIU team would refer patients for services such as mental health care or physiotherapy and occupational therapy to assist with mobility, falls prevention and management of symptoms.

Patients would also be provided with practical support – for example with budgeting, housing and benefits.

FORECAST IMPACT

The provision of proactive, holistic and coordinated care would improve the health and wellbeing of HIUs and ease pressure on both primary and secondary care services.

A potential annual saving of £157,326 could be achieved by a 20% reduction in GP appointments, 40% reduction in ED attendances and 40% reduction in emergency hospital admissions. The annual workforce cost of the new service is estimated to be £44,553 so the net annual productivity savings would be £112,773.

All roles, besides administrative support, fall within the Additional Roles Reimbursement Scheme so these costs could be partially refunded.