Case study: Developing a patient support systems to reduce hospital admission rates

Dr Julian Brown of Litcham Health Centre in King’s Lynn introduced new systems that help to identify 'at risk' patients, as well as making sure tests are not missed and important data is collected.

Dr Brown introduced a population management process to the practice. Healthcare assistants were employed to run an admissions avoidance room. Priority patients are listed on whiteboards with data updated each month to identify any key calls to action.

Each week the practice uses the Eclipse system to identify ‘at risk’ patients. Staff upload data to the system every day to get new alerts. The system runs over 2,000 algorithms against patients each day. Calls to action are identified by the team.

A specialist community support team ensures that patients unable to attend the surgery can be assessed. The community support team uses both the clinical system and the whiteboards in their office to keep up to date with changes in the care provided to patients on different registers. This had led to a reduction in accident and emergency admissions and inappropriate hospital referrals. The practice’s rate of emergency admissions was one of the lowest in the region.

Another innovation is the Patient Passport system. Patients have a smartcard that links to the data held on the practice’s system. The Patient Passport is scanned at reception when a patient arrives, alerting staff if there are any outstanding tests due or additional clinical input required. The Patient Passports are linked with local hospital data and allow the extended healthcare team to access the patient's key medical information outside of the practice.

“I make big savings by keeping people out of hospital”, says Julian. “We have created a vulnerable patient support network, dramatically reduced the admission rates for our patients and improved our ability to keep people safe. That’s what excites me.”