Reducing avoidable and unplanned hospital admissions among high users of urgent care

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Case Study Summary
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Overview summary:
NHS Vale & York CCG introduced Proactive Health Coaching (PHC), a unique delivery structure bringing together the CCG, private partner, hospital trust, community partners & independent evaluator.

PHC is a telephone-based health management service that improves patient health & quality of life while ensuring healthcare resources are spent as efficiently as possible.

The CCG with partners Health Navigator & York Teaching Hospital delivered a preventative strategy for identified patients delivering better care for patients & reducing stress on A&E.

Challenge identified and actions taken :
NHS Vale of York CCG identified that a large percentage of A&E contact in the area as avoidable. It resolved to tackle the issue head on through work that aligned with local sustainability and transformation plans and its system-wide collaboration with partners.

But the system context in Vale of York is complex. It has three local authorities, an acute and community provider, a mental health trust, a large voluntary sector and alliances of primary care practices working in locality groupings.

Added to that, the clinical commissioning group (CCG) is in special measures due to its challenging financial position and demand is growing across the footprint, with an unsustainable increase in emergency department visits in Vale of York.

To address these challenges, the CCG embarked on a collaborative project with Health Navigator and other partners to see whether it could support patients to self-care better. It also wanted to help patients to navigate the wide variety of care options, to reduce demand on emergency services, so improving patient outcomes and reducing cost to the system.
Impacts / outcomes:
In partnership with Health Navigator and York Teaching Hospital NHS Foundation Trust, the CCG delivered an effective preventative strategy for identified patients that simultaneously provides better care for patients and reduces stress on A&E departments.

Using an algorithm, Proactive Health Coaching identifies patients before they become high users of urgent care services it works by supporting patients with weekly coaching calls in a randomised control trial and facilitates:
  • putting patients at the centre of care
  • patients being able to define their own goals so they can take control of their health and care journey, using services other than A&E
  • a better experience and outcomes for patients
  • commissioners, acute providers and primary care being able to work together
  • a reduction of the burden on A&E and inpatient services by reducing unnecessary attendances from some patient cohorts
  • a more efficient use of healthcare resources.

By supporting patients with weekly coaching calls, the randomised control trial is already showing high levels of improved patient experience, a reduction in attendances at A&E and fewer unplanned admissions to hospital. Patients being supported by the health coaching intervention are also reporting more confidence in the management of their conditions.

Results from an earlier NHS case study collated by York Teaching Hospital NHS Foundation Trust are currently being evaluated and published by the Nuffield Trust, an independent health charity. The patients formally contract with Health Navigator, which at present covers a relatively small patient group of 183 study participants, of which 121 patients have had the support of a health coach. At the time of evaluation, this has yielded savings per patient in the first year of the intervention of £1,034 less than the control group. This means that the service is already close to break-even in its first year, as it costs £1,200 per person for a two-year intervention.

Based on results in Sweden, it is anticipated that those receiving the service will have a further benefit in year two, equating to around 40 per cent further savings. This should mean a total saving of £1,448 per person and a net benefit to the commissioner of £248 per person over the two-year intervention.

Moreover, there are the associated operational benefits from taking activity out of the system. In particular, the intervention group has had 63 per cent fewer non-elective admissions and 60 per cent fewer A&E attendances. The number of bed days was 17 per cent less than the control group.

All of these represent the first year of the intervention only and across a small population group. The CCG recognises that results may change as study numbers increase. It is fully expected that over time, and as a greater number of patients are included within the study, the potential impact is normalised out across the population and the end result may be a slightly lower number, but the trend is clearly a positive one.

These early results mirror the significant impact that has been seen in the much larger trial in Sweden where over 12,000 patients have received similar support. Results from the Swedish trial have been published in the European Journal of Emergency Medicine in 2012 and 2015. The most recent results are showing statistical reductions of 30% in non-electives and 36% in A&E attendances.

The results also provide evidence of relevance, spread and replicability, with the initiative being easy to replicate nationally, even in financially challenged care economies. It also has the ability to be scaled up to cover a wider range of conditions.

Which local or national clinical or policy priorities does this innovation address:
NHS England’s Five Year Forward View - NHS England’s Five Year Forward View states there is a traditional divide between primary care, community services and hospitals, largely unaltered since the birth of the NHS, is increasingly a barrier to the personalised and co-ordinated health services patients need. The NHS will increasingly need to dissolve these traditional boundaries. Long term conditions are now a central task of the NHS; caring for these needs requires a partnership with patients over the long term rather than providing single, unconnected ‘episodes’ of care. Proactive Health Coaching allows for services to be integrated around the patient.
Plans for the future:
This is an exciting time for Health Navigator UK. We are encouraged by the progress we are making and are delighted to have secured a number of significant contracts to deliver new and innovative healthcare services in the UK.

Proactive Health Coaching is being delivered together with various CCG partners in England and will be evaluated by the Nuffield Trust on a yearly basis.

We are at the start of a significant growth phase but acknowledge we cannot do it alone and we are seeking additional sites in the West Midlands to work with.

If you would like to explore this opportunity please get in touch.
Tips for adoption:
Key learning:
  • Don’t underestimate how important it is to gain buy-in from partners. Time spent working together is key to success at all levels.
  • Setting up a project to meet research standards and guidelines, and gaining ethics approval, is perhaps the most time consuming part of the project.
  • It is important to understand the finance and activity relationship between this intervention and any other scheme, coding or change targeting a similar area, as this can skew the results. It is essential to ensure you are looking at like-for-like datasets.
  • Working with patients to help them understand their conditions and navigate the system effectively has a massive impact on people’s confidence to manage their own conditions. Continuity of support and time spent early on has a lasting impact on health behaviours and use of health and care resources.

Takeaway tips:
  • Agree the inclusion process and mechanisms for contacting patients as early as you can.
  • Engage widely, particularly around governance requirements of each partner organisation.
  • Organisations such as Healthwatch are invaluable in helping to support patients and encourage participation.
  • Develop appropriate contract risk shares to provide financial incentive to the provider to ensure delivery while protecting the commissioner from exposure to the full impact of any potential non-delivery.
Contact for further information:
Ravinder Sandhu
Managing Director UK
Health Navigator Ltd

T: 07717 412543
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