COPD: A Year in the Life
The "A Year in the Life" project improved the care of more than 30,000 people living with Chronic
Obstructive Pulmonary Disease (COPD) in North East London while also reducing healthcare costs.
Partners including academics, PCT managers, primary and secondary care clinicians were keen to
improve the treatment of long-term conditions through earlier diagnosis.
The initial challenge was getting an accurate picture of patients' health needs across
four London boroughs so GPs could address long standing problems of recurring hospital
admissions and poor health.
Our software helped extract and analyse the necessary patient information leading to
improvements in diagnosis, better prescription and patient reviews.
This has led to unnecessary hospital admissions being significantly reduced, saving an
estimated £6.5 million over two years.
Project Summary
Patients at Risk
The ability to identify and treat patients at risk of illness is key to improving their quality of
life and avoiding unnecessary hospital admissions.
Community services like district nurses and health visitors play an invaluable role in ensuring
patients are treated closer to home.
Health Analytics software identified geographical areas where 90% of patients at risk of hospital
re-admission were receiving little or no support from community services.
In response, one of our customers introduced a new risk management system in doctors' surgeries.
This allowed GPs to forge closer links with community health professionals.
It provided a seamless service where everyone had a better understanding of their patients' needs and
who was best placed to support them.
Financial reporting
A major concern for clinical commissioning groups is getting a clear understanding of
the financial responsibilities they will inherit from outgoing Primary Care Trusts.
Primary care trusts are responsible for delivering a wide range of health services and are
subject to strict regulations about how they spend their multi-million pound budgets.
It's an intimidating challenge for anyone who isn't familiar with the financial ebb and flow
of a national organisation with an annual budget of more than £80 billion.
A group of GPs asked Health Analytics if they could create a financial reporting tool that could
clearly sum up their primary care trust's financial position on a monthly basis detailing its
income and expenditure.
The result was a concise understanding of where money was spent and, as a result, a savings
programme was successfully introduced.
It is also led to a better relationship between GPs and the Primary Care Trust through a clearer
understanding of one another's needs.
Claims management
Hospital treatment might be free for patients, but it certainly isn't for commissioners.
The average primary care trust receives a monthly bill of £25 million from hospitals who've
treated their patients. This includes GP referrals, A&E attendances and surgical procedures.
Hospitals pass on the bill to trusts via the National Programme for IT, where "procedures" such
as a hip replacement or a heart bypass are coded and assigned an agreed tariff.
It's worth noting that this is all but impossible to understand unless you are a GP or practice manager with a
lot of time on your hands and some knowledge of the patients concerned. The tariff information is six weeks
old by the time commissioners receive it, and they are given just five days to check the bill.
Health Analytics introduced an automated challenge system which provided a Primary Care
Trust query up to 20% of its monthly hospital invoices. Common challenges include hospitals identifying
the procedures incorrectly, duplicated charges, and billing the wrong Primary Care Trust.
In addition, we helped individual practices implement their own challenges. Our systems provided
online access to patient charges specific to their own surgeries.
This saved GPs and practice managers a huge amount of time, with one practice challenging more than £200,000 worth
of invoices in one month.
QOF Optimisation
Health Analytics' software provides pan-PCT or pan-consortium tracking of QOF metrics. The same
analytical software is used by both Practice Managers and Commissioners, eliminating the need for
traditional reconciliation processes. Comparison of QOF performance across the organisation is trivial, and encourages
process improvement. Practice managers can rapidly identify areas requiring attention and drill-down
to their patients to correct problems.
One customer raised child immunisation rates across the PCT by an average of 10% through use
of Health Analytics' analysis software to find patients who had not been immunised or whose
immunisations had been incorrectly coded.
Integrated care management
Our risk stratification tool is the driving force behind efforts to reduce unplanned hospital
admissions.
The problem costs the NHS an estimated £11 billion a year so the ability to predict the likelihood
of admissions and offer preventative care has huge implications in terms of health care and savings.
It seems logical that doctors and nurses are best placed to make these predictions but our risk
stratification tool has two main advantages.
It can comprehensively screen populations on a regular basis as well as make predictions about patients
that clinicians don’t even know about.
Our software identifies the top 1% of patients most vulnerable to hospital re-admission proving
integrated case management teams (ICM) with valuable insights into who would benefit from more
support. We can also analyse how effective care teams are. Independent analysis suggests that ICM
can reduce admissions by between 25% and 50% using our software.
Atrial Fibrillation
Atrial fibrillation - an irregular and often abnormally fast heart rate - is a deciding factor in 14% of all strokes.
The condition affects more than half-a-million people in the UK, who have increased vulnerability to stroke
caused by blood clots forming in the heart and entering the bloodstream.
Our risk stratification software identified high-risk patients providing an automatic alert system for
the prescription of Warfarin, an anti-coagulant that reduces the threat of clots.
This saves an estimated five patients a year from a stroke as well £44,000 in hospital care per patient.