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Gavin MacColl: Anticipatory care planning in primary care
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Gavin MacColl: Anticipatory care planning in primary care


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  • 1. SPARRA and anticipatory care planning in primary care Gavin MacColl ISD Scotland
  • 2. Overview • Context • Overview anticipatory care planning & SPARRA • Practice data • Practicalities • Evaluation & Feedback
  • 3. Context – GMS contract • Health and Social Care Integration – Integrated adult health and social care budgets - Health Boards and Local Authorities – A requirement on Partnerships (currently CHPs) to strengthen the role of clinicians and care professionals, along with the third and independent sectors, in the planning and delivery of services • 2013/2014 GMS contract – Focus primary care resources on the most vulnerable patients in the community – Support and value the work of the wider Primary Health Care Team based around the GP practice – Anticipatory Care Planning (ACP) activity to replace QP QOF indicators on A&E and emergency pathways – 6 new QOF indicators focus on at risk patients, with a focus on ACP/polypharmacy
  • 4. SPARRA • SPARRA - Scottish Patients at Risk of Readmission & Admission • Risk prediction algorithm developed using logistic regression on a patient level dataset • SPARRA Version 3, launched in January 2012 • SPARRA scores (%) calculated quarterly • Data for patient risk stratification provided to Health Boards and to General Practices
  • 5. SPARRA V3 Risk Factors & Datasets Outpatient (1 year) Emergency Department (1 year) Prescribing (1 year) Outcome Year (1 year) OUTCOME PERIOD Hospitalisation (3 years) PRE-PREDICTION PERIOD Psychiatric Admission (3 years) Any recent admissions to a psychiatric unit ? Any A&E attendances in the past year? What type of outpatient appointments did the patient have? Any prescriptions for e.g. dementia drugs? Or substance dependence? How many outpatient appointments? What age is the patient? How many previous emergency admissions has the patient had? How many prescriptions? Any previous admissions for a long term condition (such as epilepsy?
  • 6. Three Sub-Cohorts New cohorts ….. • Long Term Conditions – aged 16-74 • Frail Elderly – aged 75+ • Younger Emergency Department – aged 16-55 – At least one ED attendance in previous 12 months …. new opportunities …
  • 7. SPARRA for Case Finding • Maximise value of anticipatory care by targeting patients most likely to benefit from interventions (medium-high risk) • First, stratify the population; SPARRA stratifies on basis of risk of hospital admission • SPARRA lists help identify patients who may benefit from preventative approach & to ensure that patients are known to the relevant services
  • 8. SPARRA - ACP - KIS Anticipatory Care Plan Polypharmacy/ Medicine Review SPARRA Patient Listing Key Information Summary Provide the relevant community interventions Evaluation ~40,000 patients
  • 9. SPARRA & Polypharmacy • CEL36 and appropriate prescribing • Age 75+ • SPARRA risk score 40-60% • On medications from 10+ BNF Sections • Prescribed at least one high risk medicine 2.1 – Positive inotropic drugs 2.2 – Diuretics 2.4 – Beta-blockers 2.5 – Hypertension and heart-failure 2.8 – Anticoagulants and protamine 2.9 – Antiplatelets 4.1 – Hypnotics and anxiolytics 4.2 – Antipsychotics 4.3 – Antidepressants 10.1 – Drugs used in rheumatic diseases and gout Polypharmacy/ Medicine Review
  • 10. ACP - KIS Anticipatory Care Plan Key Information Summary Signpost/ refer/ provide the relevant community interventions • Support for self-management • Homecare / re-ablement • Carer support • Peer support / befriending • Falls prevention • Exercise • Telehealth / telecare • Housing adaptations and equipment • Other health and care supports
  • 11. SPARRA - ACP - KIS Key Information Summary
  • 12. Practice Data: QOF Indicators for High Risk Patients “The practice produces a list of 5% of patients in the practice, who are predicted to be at significant risk of unscheduled admission or unscheduled care.” o Average practice: 5,550 patients 5%: ~280 patients “The contractor identifies a minimum of 15% (in 2014/15, 30%) of those patients from the list produced in indicator above who would most benefit from, and creates, an Anticipatory Care Plan (the ACP must include a poly-pharmacy review)” o 15% at risk population for ACP: ~40 patients
  • 13. Practice Data: Indicative numbers ~ 5% of practice population
  • 14. Practice Data • Use SPARRA as a screening tool to identify at risk patients • Suggested focus on 40-60% grouping for patient ACP selection • Clinical judgement should also be used with SPARRA scores • Iterative process – new and untested in QOF
  • 15. Version 3 Model & Limitations • Quarterly risk scores for around 80% of population • Predictive of 95% of emergency admissions overall • Timeliness - deaths data should be accurate at time of data extract – requires early review of data • Limitations of using SMR data, e.g. issues with coding of LTCs and data quality / primary vs. secondary care information • In future, use primary care data for LTC? • Automation and monthly production of data (iSPARRA)
  • 16. How do you get your data? • Push (Health Boards) vs. Pull (SPARRA online)
  • 17. Evaluation – Board/CHP Level • Case studies/Evidence Base • Aberdeenshire CHP: 65+ ‘Stay well’ & ACPs • NHS Fife: COPD, Heart failure, polypharmacy • NHS Highland*: Nairn Case Finder • Glasgow City CHP: >65 and 60%+ risk, 1+chronic conditions *Baker A et al Br J Gen Pract. 2012 Feb;62(595):e113-20.
  • 18. Evaluation of ACP & 4 QOF indicators • Internal practice review the data on emergency admissions provided by the Board and the learning from at least 25% of the Anticipatory Care Plans (ACPs) completed • External peer review with either a group of local practices, or practices from the Board area, data on emergency admissions shared learning from at least 25% of the ACPs; proposes areas for internal practice improvement or service design improvements for the Board
  • 19. Evaluation of ACP and QOF • Multi-disciplinary meetings during the 2013/2014 FY to review active management plans, identify learning needs and related changes in patient management. These meetings should be open to professionals who support the practice's patients. • Practice reports annually to the Board on internal practice and wider Board system changes that may benefit patients. The report will include Significant Events Reviews (SERs) on 1/1000 patients, to a maximum of 3 per practice, of patients with ACPs from the cohort, who were admitted during the year, after their ACP had been created
  • 20. Future • Local risk prediction (GP data) • Social care data and availability • SPARRA and telehealth • Improvements: – to SPARRA itself – automated SPARRA – how data is accessed and used
  • 21. Contacts / Acknowledgements • ISD SPARRA team: – Website: – – E-mail: