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Organisation develops a project to improve the lives of people aged above 75, offering appropriate interventions and empowering them to live an independent life

Challenge

    • More than half of all 75 year olds in the UK live alone
    • Optimise the overall health and wellbeing of lonely, socially-isolated and frail older patients aged above 75
    • Improve socialisation and reduce the dependence on the health and social care system by the ageing population
    • Reduce the use of secondary care and minimise preventable hospitalisations

Action

    • Set up Prime75+ to improve health among the over 75s
    • Created a risk stratification tool identifying patients at risk of becoming lonely and/or isolated
    • Created referral pathways and protocols for GP systems to proactively refer/capture/track activity and outcomes
    • Appointed a coordinator to identify people who are lonely, socially isolated and frail and offer appropriate interventions

Result

    • 26% decrease in GP appointments from high demand patients across the four participating practices
    • Reduced avoidable and unplanned hospital admissions by 5%
    • 3% reduction in A&E attendance by participating patients
    • Reduced dependency on healthcare services
    • Improved mental and physical health for those identified as lonely

More than half of all 75 year olds in the UK live alone, with frailty a strong predictor of negative outcomes including disabilities and institutionalisation, acute illness, and increased vulnerability. This presents major challenges for primary care providers and the wider health and social care system, exacerbated by increasing financial constraints.

Prime75+ was set up to enhance socialisation and improve health amongst the over 75s, and decrease dependency on health services, through delivery of personal and patient-led interventions. The project has seen phenomenal results – a 26% decrease in appointments from high demand patients and increased levels of patient (and practitioner) satisfaction.

Challenges

To optimise the overall health and wellbeing of lonely, socially-isolated and frail older patients aged 75 and over To support the continuity of independence of the over 75 population To improve socialisation and reduce the dependence on the health and social care system by the ageing population To reduce the growing pressures on primary care providers To reduce the use of secondary care and minimise preventable hospitalisations

Actions

Collaboration with NHS South Warwickshire CCG and local GP practices to identify how the needs of patients aged 75+ were currently being addressed. A series of in-depth meetings with practice staff and patients, with all those within the community involved in the health and wellbeing of the 75+ population, and with the voluntary sector around current intervention and provision. Creation of a risk stratification tool identifying patients at risk of becoming lonely and/or isolated, referral pathways, templates, concepts and protocols for the GP systems to proactively refer, capture and track activity and outcomes, documented in a ‘how to’ guide for practices.

Appointment of a dedicated. Coordinator whose role was/is to oversee the project and work alongside clinical and reception staff to identify those within the respective practice who are lonely, socially isolated, and frail and offer appropriate, coordinated interventions. Liaison with partner organisations from across the community to facilitate the provision of health, social and voluntary care interventions

Results

26% decrease in GP appointments from high demand patients across the four participating practices 5% reduction in avoidable and unplanned hospital admissions 3% reduction in A&E attendance by participating patients (compared to a 7.6% increase in A&E attendance by non-participating patients) Enhanced capabilities of primary care providers in prioritising patients in real need of medical attention Increased levels of satisfaction across both patient (over 75s and other cohorts) and healthcare practitioners

Value

The value of the contract is approximately £70,000 per annum. This covers a full-time Coordinator, fund provision to the four participating GP practices to facilitate the organisation and hosting of patient activities, and a sub-contract with the voluntary sector for referrals to secure robust monitoring and evaluation Since launching in January 2015, the scheme has facilitated contact with 701 patients from across the four practices and has conducted 291 initial assessments.

The Coordinator has liaised with more than 43% of the total population of over 75s, has completed full assessments with 18% of those individuals, and has identified approximately 21% who are lonely. If rolled out on a national basis, based on an average £35 per ten minute appointment, a CCG with a population of 200,000 could potentially save 88,800 GP surgery appointments and £3.1million per year. For the NHS as a whole, this would mean a saving of over 24 million appointments and £236million in avoidable admissions.

In detail

Ambition

It’s widely acknowledged that focusing attention on patients that are lonely, isolated or frail delivers quantifiable and improved quality of life, medical outcomes and general well-being. With a greater focus on prevention, with coordinated, convenient, safe, and reliable care delivered within general practice in partnership with the local community, Prime 75+ moves away from a traditional model of care which focuses purely on health issues, and instead looks at the overall physical, mental, and social needs of those over 75. This innovative, yet simple model, harnesses the power of collaboration and strongly supports evidence that self-management, personalised care planning, and shared decision-making are all highly effective means of giving individuals greater control of their own health. Patients who are actively involved in their own care experience more positive outcomes, and are less likely to be hospitalised.

Outcome

The project has proved hugely successful, not only achieving financial savings month-on-month, but helping reduce unplanned and avoidable hospital admissions and reduced GP appointments. In addition, it has been well received by all patients involved, who have praised the help and support they’ve received, which has empowered them to live a more independent and happy life. The success of the project is measured by monitoring the impact it has had on the individual it’s working with, using primary and secondary care data and also noting significant reductions in the number of elderly people visiting their GP, and subsequently A&E admissions, as a result.

Prime 75+ has not only helped tackle current issues. The team has found that they have been able to identify some personal or social issues that don’t initially have a direct impact on GP visits or hospital attendance, but left untreated could escalate and result in a potential crises for the individual, increasing demand and pressure on health and social care providers.

Spread

The team behind the Prime75+ project puts its success down to its patient centered approach, management of current demand, personalised self-care and the relationships built and nurtured along the way, support from these has been integral. Partnerships have included the CCG, allied charities such as The Silver Line, and of course the patients, practices and wider communities themselves. It is this collaborative, and forward-thinking, approach that has enabled the team’s real ‘can-do’ attitude and has helped them to overcome and tackle head-on the challenges associated with this innovative model of care, and to identify key aspects of success which it can build on in the future

Whilst initially piloted across South Warwickshire, the project’s early successes mean it can be replicated and rolled out across other regions in the future (it is already in the process of being scaled-out across the South Coast). The project was easily implemented within eight weeks of funding being awarded, primarily due to the expertise of the Prime GP team, and the development of clear guidelines outlining everyone’s roles and responsibilities.

Two enablers have meant that the intervention is successful and scalable:

1.Specialising primary care by focusing on a specific patient population – those involved develop deep expertise in the care and the coordination of patients

2.Changing the clinical culture to enhance scalability – Prime GP started with four practices and developed a process for monitoring, evaluating, communicating, and developing the right mind-sets and behaviours among the group that hold them accountable for performance

Value

The project has proved hugely successful, not only achieving financial savings month-on-month, but helping reduce unplanned and avoidable hospital admissions and reduced GP appointments. In addition, it has been well received by patients, who have praised the help and support they’ve received, which has empowered them to live a more independent and happy life.

Measured improvements in patient care include:

- Reduced dependency on healthcare services

- Avoidance of unplanned, avoidable admissions

- Improved mental and physical health for those identified as lonely

- Reduced A&E and emergency inpatient activity

- Reduction in the unnecessary use of health and social care services

- Reduction in hospital admissions

Not only is the model impacting significantly on the socialisation, morale, and overall health of those involved, the project is also seeing huge annual savings being achieved – providing CCGs and the public the reassurance of a high quality service that is proven to improve health and wellbeing while ensuring that the investment brings value for money. Following the initial successes of the initiative across South Warwickshire, it has now been commissioned by NHS Eastbourne, Hailsham and Seaford CCG and is currently being implemented across four practices across East Sussex, with further roll-outs planned for 2017/18.

Involvement

Key to the initial success of this project has been patient engagement, as well as the acknowledgement that change is not something that happens with just one appointment. Indeed, the most powerful impact begins to happen when a genuine, trusting relationship is built which replicates that which the patient has with their doctor. The Prime75+ model thus demonstrates the importance of a single point of contact within the GP practice, who is an expert in supporting older patients, and who understands the community and the support available. The needs and support of each patient inevitably varies, and the Coordinator seeks the views of the patients themselves about the support and level of engagement required, and works with them to identify the health or social care intervention best suited to them.

Older patients are then put in touch with voluntary organisations, charities and community services and encouraged to engage in activities or services that they may benefit from. Where there are gaps, they work together to organise and coordinate activities that are appropriate to patients’ needs and desires – anything from first aid courses and gardening projects, to mosaic classes and tea parties (including a 20,000 Year Tea Party which saw the collaboration of the biggest over 75 patient group in the history of the NHS). This not only promotes the development of friendships and self-confidence, but reduces the reliance of the individual on the one person they previously saw as their sole trusted confidante – their GP.

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Amy Danahay