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Innovation 'Elevator Pitch':
Sometimes it’s hard to prove impact. Risk Tracker helps organisations providing preventative services to record their work & demonstrate success. Provided free for anyone to use (under open license) Risk Tracker is for use on desktop & mobile devices
Overview of Innovation:
Risk Tracker is a powerful tool for managing clients and demonstrating outcomes. Designed to record information without getting in the way of the service you provide, it requires collection of a minimal amount of information from clients, but provides you with the flexibility to customise.

One of the key challenges for organisations who provide preventative services is connecting your clients’ progress with the complex range of National Outcome Frameworks. Inside Outcomes continuously maintains the policy environment to ensure that your reports will always reflect the most recent National Outcome Frameworks and, as the Frameworks evolve, we keep you up to date with the impact this will have on your day-to-day operation.

We have collated a database of issues that are common to preventative services. The system has been designed to support care navigation services by providing a quick tool to record client notes, measure outcomes and store files.

The Inside Outcomes Risk Tracker tool helps organisations to:
  • Record the common issues that clients present to services
  • Measure changes in those issues over time
  • Demonstrate the impact organisations have had in an evidence based way
  • Measure the impact organisations have had against National Outcome Frameworks
We have created a series of custom Risk Maps that reflect the issues clients commonly report, and aligned them with the public health life course. These Risk Maps cover diverse issues such as financial planning, housing and wellbeing, because we know the complexity of individual circumstances has an impact on your ability to provide services.

Our Risk Maps cover: We are also able to tailor risk maps to reflect service specific needs such as:-
We also provide the facility to run anonymised open data reports that highlight social need in a particular area. Because we used a standardised format for recording the issues that people present we can aggregate data across multiple agencies to create a powerful, live commissioning tool.

We provide Risk Tracker free for anyone to use. We provide it under an open license so that you can run it in any way you want or even adapt the code for your own uses. You can access the code repository on our Github site. You can access the Risk Tracker manual here.
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
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Innovation 'Elevator Pitch':
Using  a person centred approach to create socially useful data. Demonstrating outcomes in terms of national policy allows data to be aggregated for social benefit. Data can describe the communities we live in and help to co-produce services.
 
Overview of Innovation:
We produce a number of open source tools to help manage clients and demonstrate outcomes. Our tools support organisations to get a rapid understanding of the full range of issues a person wants help and support with. Using a simple, whole person, assessment process we help organsiations to take a person centred approach which wraps services around the invidual. 

Our tools provide a secure and easy way to share information across services but also gathers anonymised data on a population level. Our approach to gathering data on clinical and social need provides a basis for area based commissioning by describing communities and neighbourhoods.

Out two main tools are Risk Tracker, a case management and outcome measurement tool and Referral Tool, a system that quickly links people to local services. We provide fully managed and hosted solutions to organisations on our secure cloud servers. Our hosted solutions allow data to be anonymously aggregated across organisations to provide live data on clinical and social need. 

Our systems are linked to a database that collates policy from National Outcome Frameworks, Government Strategies and best practice from NICE. This allows services to report the impact they have in relation to the outcomes that their funding organisations and commissioners are accountable for. As policy and outcome frameworks change, we reflect those changes in organisational reports. 

All of our software is available under an open license to ensure sustainability and allow integtration with existing bespoke systems. 

The Inside Outcomes approach to case management and making referrals have been designed to support anyone that works in a community navigation role, or within social prescribing and general face to face prevention services. 

 
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Innovation and adoption / Person centred care
Benefit to NHS:
Health is influenced by a range of social, environmental and economic factors which are beyond the remit of the health sector.
 
Health services, social care and housing are all focused on delivering better outcomes at lower cost to the public purse and finding ways of improving the effectiveness and better understanding the value of preventative services.
 
Risk Tracker measures the impact of organisations against national outcome frameworks, supporting them to translate the things they do into the outcomes that commissioning bodies are measured against. Referral Tool makes the referral process between organisation more efficient and promotes better service integration.
 
Commissioners need to identify what services are required to deliver improvements in the prevention, diagnosis and treatment of physical and mental illness in their local population, Risk Tracker provides important data to identify top priorities and opportunities for transformation.
 
It helps commissioners to identify subgroups within their population and consider service requirements across the system, creating the person-centred services patients want and need.
 
Our tools allow a simple method to analyse population data and identify those who would gain most from the services and interventions, commissioners then use this information to plan, deliver and monitor services for their local population.
 
When contracting for services, commissioners are looking for positive social outcomes, which have a lasting impact; with benefits for patients that can be clearly demonstrated.
 
With Risk Tracker, information is used to improve services and influence commissioning decisions. For example, the crossover in issues that the clients present to substance misuse services, mental health services and housing associations mean that data can be aggregated together.

As all data is stored in a single, secure, compartmentalised system we can create aggregated, anonymised maps of social need. The live data that can be produced records social need and is an essential tool in commissioning services against evidenced social need.
 
Investing in prevention and better health outcomes can be part of the solution to the challenges of increasing levels of need along with shrinking budgets. Effective preventative interventions can reduce health and social care costs and the need for welfare benefits. Better health can also enhance resilience, employment and social outcomes.
 
 
 
Initial Review Rating
4.60 (2 ratings)
Benefit to WM population:
Risk Tracker helps commissioners to plan services which meet national standards and local ambitions, by combining knowledge of existing service performance and population needs. Referral Tool provides a way for services to integrate around an individual, creating a person-centred approach whilst collecting minimal information. 
 
Commissioners traditionally do not have access to live local data. Having the ability to extract accurate data on health and wellbeing needs for a particular area supports a flexible approach to commissioning against need. Open data on social and clinical need also creates a basis for the co-production of services that match the needs of communities. 
 
The methodology that underpins our system encourages services to carry out a whole person assessment.  This means exploring the range of issues that might be present in an individual’s life. Through identifying a range of interdependent issues, services can integrate how they work with an individual and improve their outcomes.
 
An important component of planning for transformation is recognising where services may
need to be decommissioned. Risk Tracker can help to identify where less effective approaches to service delivery are to be found. With a good understanding of how a service is currently operating, commissioners can identify potential opportunities for innovation and improvement. Our method of mapping and recording referrals also can identify where services are not linked up providing an opportunity to increase efficiency and reduce costs. 
 
Risk Tracker and Referral Tool support commissioners to develop service specifications that focus on paying for services which produce improved outcomes for their patients, rather than reimbursing providers for activity.
 
All of our tools provide commissioners with the information they need to develop a vision of future service provision that will improve the health & wellbeing of individuals and communities in the West Midlands.
 
We provide hosted and managed solutions for a range of organisations. Our cloud servers provide a scalable solution that is secure and dynamically allocates resources to meet to demand. All of our software is also provided under an open license in order to promote sustainability and integration with other systems. 
 
Current and planned activity: 
Our Risk Tracker system is currently being used across Birmingham in GP surgeries as part of a contract with Citizens' Advice. It is also being used to support Health Trainers, Pregnancy Outreach Workers and Pre-Diabetes Group work. We also support Social Prescribing Projects in Birmingham and Oldham. 

Referral Tool is being used across Sandwell and is available for use by any organisation in Sandwell. 

We have recently received a number of grants for a range of outcome work.

We make this application to the SME Fund in order to get working capital to finish off software development of Risk Tracker, achieve NHS IT security accreditation, develop network mapping capabilities in Referral Tool and supplement marketing activities. 
 
What is the intellectual property status of your innovation?:
The intellectual property for all software is owned by Inside Outcome CIC. Our software is released under an open license. 
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
6-12 mon
Ease of scalability: 
Simple
Regional Scalability:
Both Risk Tracker and Referral Tool have been built to scale across large areas. The aim of the apps is to generate population level data on social and clinical need. Consistent data across large geographical areas. 

The key areas where we are looking at scale is to extend the use of Referral Tool. At present it’s operating across Sandwell Metropolitan Borough Council. We are seeking to extend this across the West Midlands Combined Authority by developing capacity to map organisational relationships and generate sustainable directories of services. 

Risk Tracker is operational across Birmingham generates data to support commissioning. We need to invest in development of the app in order to better manage organisations that work together. This will increase the ability to scale across neighbourhoods. 

Both Risk Tracker and Referral Tool are designed to operate sympathetically, to capture data from organisations that need a client management tool and those that want to manage data.
Measures:
We are working to achieve a number of outcomes in our short term plan. We will achieve compliance with the NHS Data Security and Protection (DSP) Toolkit. We will complete our pilot data generation project in the Northfield district and use that data to work with Birmingham City Council to design services. 

We will be able to demonstrate outcomes, in relation to services and areas, from the NHS, Adult Social Care, Public Health, Social Jusitce and Social Prescribing Outcome Frameworks. 
Adoption target:
We have achieved minimum viability through commercial sales to date. We are looking to progress pilot projects, in partnership with the NHS, to demonstrate how we can generate data on a larger scale. In the coming year we are looking to expand the use of Referral Tool from Sandwell into the West Midlands Combined Authority area and Staffordshire. 
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Innovation 'Elevator Pitch':
Crowdsourcing the most appropriate referrals to improve pathways and promote integration. Using whole person assessment to enable to agencies to work together more efficiently around an individual. 
Overview of Innovation:
Referral Tool app has been designed to quickly identify local organisations that you can refer clients to. It’s been created to complement any data system you use, entirely focusing on improving the quality of referrals.

The system works through carrying out a brief whole person assessment. This involves talking to the client and trying to assess the full range of issues that they are looking for help and support with. Using our simple Risk Maps these issues can be quickly recorded.

Both clients and workers are presented with a succinct list of appropriate referral agencies for the issues identified. Through creating a holistic approach to providing help and support agencies can tackle those complex issues that require joint working, therefore, improving outcomes. 

We have created this to be used across a local area with all of the organisations using it to crowdsource the most effective agencies to help resolve problems. As agencies understand the issues they are best placed to resolve they can manage which clients are referred to them. This dispersed system of management means no one agency is required to keep data up to date. As a result, this is a sustainable system created to reduce central management costs. 

Every agency can customise the system to reflect the sort of issues that their clients present. Which means the assessment process is simplified to focus on the things that are most important to the person in front of you and can be carried out in a matter of minutes. 

Designed to focus on services such as social prescription or community navigation, Referral Tool can be easily used by any agency that carries out face to face client work. 

As all issues raised are recorded in the same format, Referral Tool also generates open data reports to identify patterns of social need in an area. This can be used to inform commissioners on where the most pressing commissioning needs are. 

Referral Tool is released under an Open License for anyone to use in any way that they want.
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Long term conditions: a whole system, person-centred approach / Wellness and prevention of illness / Digital health / Person centred care
Benefit to NHS:
As many people present to service with complex issues it is rare that a single agency can resolve all issues. Where issues are interdependent on each other then it is essential that agencies work together coherently to support an individual. Referral Tool provides an easy method  to identify relevant local agencies and how to make a referral.

This avoids many of the problems of service directories as there isn't a need to keep the referral data up to date, this is manged by agencies. It also does not require someone looking for referral agencies to second guess how to search for agencies 

As all data is collected in the same format Referral Tool can also produce geographical maps of need to demonstrate where commissioning priorities should be set. 
Initial Review Rating
3.40 (1 ratings)
Benefit to WM population:
The WM population benefit on a number of levels. More integrated services mean that they do not have to seek help from a wide range of sevices. A seamless referral process is less likely to discourage people from taking up services they are offered. 

As Referral Tool can generate live data on local need then commissioners have an evidence base for how they can target services to address local need. 
Current and planned activity: 
We are currently using Referral Tool across Sandwell but this is voluntary sector promoted activity rather than via the NHS. 
What is the intellectual property status of your innovation?:
We own the intellectual property of our Referral Tool product but make it available to anyone under an open license.
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
Simple
Regional Scalability:
This tool can be easily scaled across the West Midlands region. We are in the process of rolling it out across Sandwelll. The Sandwell roll out has been fully funded and can be used by anyone in that area. For the best outcomes the tool functions in local authority areas in order to ensure that referrals and pathways are most appropriate to clients and patients. 
Measures:
We are guaging success by measuring penetration within face to face services where the tool is being implemented. This can be easily measured through the way the tool creates open data maps of social need in a given area. 
Adoption target:
We are looking to implement the Referral Tool in each local authority area in the West Midlands. 
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Innovation 'Elevator Pitch':
Elemental’s Social Prescribing platform is an easy to use, cloud-based, responsive platform that enables community referrals to be implemented, measured and delivered across numerous health and social care scenarios.
Overview of Innovation:
Elemental Software, is a Tech For Good company with the purpose of engaging & empowering people & communities towards better health outcomes. This involves creating meaningful connections between people & their communities to address the wider determinants of health & to reduce health inequalities.

Elemental’s approach in reaching more people & connecting them into community-based programmes & services such as walking groups, healthy cooking courses & mindfulness sessions led them to create a platform that gives health & social care providers ease, peace of mind & quality assurance in making, receiving & reviewing community referrals otherwise known as Social Prescribing.

The team at Elemental has been at the forefront of mobilising communities towards better health, education & employment for the past 30 years combined. Their experience led them to see that despite millions of pounds being spend on preventing conditions like obesity, diabetes & depression the challenge remained in engaging those most at risk. Chronic conditions are rising & so too are the costs. Elemental know that involving someone in creating their own health risk prevention plan is key to empowering them towards living better quality lives.

With The Elemental Platform you can:
  • Facilitate more people accessing & engaging in Self Care Programmes in your area
  • Reduce the amount of time between referral & first engagement
  • Connect different stakeholders in your area (VCSE, Health/Social Care & communities) providing more choice for what matters to the individual
  • Provide performance related metrics & analysis around referral activity across teams, locations & types of healthcare establishments
  • Minimise the risk of people ‘opting out’ of programmes
  • Develop the capacity of your workforce across multiple sites
  • Reduce administrative tasks & free up more time to support individuals
  • Measure the progress & impact of programmes
Despite all of our best efforts we tend to work in separate silos. We can’t all be expected to know everything that’s happening in someone’s local community. Whether you are a resident, GP, social worker, commissioner, social prescriber or community provider we don’t always have the time to source information & make connections that positively impact on someone’s life. We could do this alone, but it wouldn’t be as effective. By connecting resources, people, programmes, partners & strategies we can support those in need so that no-one is left behind.

To view our video click on the image.

Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Wellness and prevention of illness / Digital health
Benefit to NHS:
Interest in social prescribing, where patients are referred to local, non-clinical community services such as walking clubs or self-help groups is on the increase across England. There is growing recognition of its potential to help meet the ambitions of the Five Year Forward View & of sustainability & transformation partnerships to support people in managing their own care.
 
Social prescribing enables GPs, nurses & other primary care professionals to refer people to a range of local, non-clinical services. It is estimated that around 20% of GP appointments are for ‘non-medical’ needs which is as frustrating for GPs as it is for patients as a 10-minute consultation producing a medicine prescription is often not appropriate.
 
Social prescribing enables a GP or other healthcare professional to refer a patient to an organised scheme which usually involves link workers or navigators taking time to understand what the patient’s needs & goals are & helps them to access appropriate services.
 
The Elemental Platform helps to address the challenges surrounding reducing health inequalities making it easier to help communities to get the support they need to address the issues beyond clinical needs that impact on their health & wellbeing.
 
Elemental connects all key stakeholders from the GP to Link Workers, the providers & the patients.
 
Platform features:
  • Referral generation: via browser on a desktop, mobile device or within specific Clinical Systems. Referrals can be made within 45 seconds to link workers & sent instantly. Referrals are tracked, viewed & analysed
  • Health risk analysis: helping individuals to better understand their health risk & track their health risk status using validated monitoring tools
  • Social prescription generator: referring individuals to a range of quality assured community-based lifestyle interventions
  • Attendance tracker: facilitate, track & measure attendance rates of individuals across multiple community-based lifestyle intervention providers
  • Health impact measurement: track an individual’s health & wellbeing improvement journey in real time & in line with identified health risks
  • Enhanced directory of services: enables accredited VCSE providers to create & edit database of venues, interventions & allocate appropriate facilitators
  • Aggregate reports: provides accurate comparative epidemiological information to facilitate greater reporting between CCGs, local authorities, Housing Associations & VCSE organisations to benefit entire communities
Initial Review Rating
5.00 (1 ratings)
Benefit to WM population:
There are an estimated 4.032 million people in 2014-15 living in the West Midlands Combined Authority (WMCA). The population is culturally diverse, with over 22% from Black and Asian Minority Ethnic communities, ranging from 2.3% in Cannock Chase to 42% in Birmingham.
 
Over half of the population of the WMCA live in the 20% most deprived areas in England. There are links between insecure housing, financial stress, mental health and child development, which influence on life chances and social mobility.
 
Data from the ONS subjective wellbeing survey points to wide variations between West Midlands Local Authorities with rates of wellbeing that are below the national average for Wolverhampton, Birmingham and Coventry and above average for Sandwell.
 
Social prescribing has been identified by Simon Stevens, CEO of the NHS, as one key way in which the NHS can change from “a ‘factory’ model of care and repair” to one that focuses on much wider individual and community engagement (Five Years Forward View, NHS England, 2014 – henceforth referred to as the Stevens Report). Social prescribing is a way of linking patients in primary care with sources of support within the community, usually provided by the voluntary and community sector, offering GPs a non-medical referral option that can operate alongside existing treatments to improve health and wellbeing.
 
Social Prescribing is recognised for the benefits it can bring for patients. These include better quality of life, improved mental and emotional wellbeing, and lower levels of depression and anxiety. It also has the potential to reduce patients’ reliance on NHS services, easing pressure on accident and emergency wards and hard-pressed GPs.
 
A social prescriber does not prescribe the solutions, but provides the environment in which the person can consider their options and help form their own plan of action. Elemental know that involving someone creating their own health risk prevention plan is key to empowering them towards living better quality lives.
 
By connecting resources, people, programmes, partners and strategies, we can support those in need so that no-one is left behind.
 
The Elemental Platform simplifies and streamlines the process of referring individuals from a GP to social prescribing hubs in the local area which could support and connect individuals and their community.
Current and planned activity: 
Currently we have been engaging with the key social prescribing leads in NHS through the Social Prescribing Network. We have been attending events across the UK engaging in Social Prescribing discussions and sharing knowledge. We have a strong footprint in Northern Ireland and would like to raise the profile of our Social Prescribing Platform and support Social Prescribing initiatives in England. We also lead a Social Prescribing Hour via twitter every Wednesday 8-9pm encouraging Social Prescribing discussions.
 
Our planned activity is to engage with a number of key stakeholders in the region and we require WMAHSN’s support in identifying relevant contacts in order to hold initial conversations.
Return on Investment (£ Value): 
high
Return on Investment (Timescale): 
6-12 mon
Ease of scalability: 
Simple
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