1. Using Predictive Modeling
A view from the Frontline
Helen Lyndon
Nurse Consultant
Older People and Long Term Conditions
Community Matron and Telehealth Clinical Lead
Cornwall and Isles of Scilly Primary Care Trust January 2010

2. I plan to cover….
• Background to why and how we use predictive modelling
• Impact of modelling and targeted interventions to ‘high
risk’ patients
• Overcoming obstacles to modelling
• How we set PARR up
• Types of patient identified using PARR
• Beyond patient identification – what happens next?
• Plans for the future

3. Setting the scene…
Cornwall:
• Population of 300,00 which doubles in the summer
• Rural county + large coast line – 1,374 square miles
• 46% of people live in dispersed settlements
• Largest town – 22,000 people
• High proportion of elderly – county with 4th highest
population of over 65s
• High levels of LTCs – 21% of people have LTC compared
with national average of 18% (2001 census)
• Levels of those aged 85 and over predicted to double by
2011

4. Setting the scene…
Emergency Admissions – the problem:
• Cornwall national outlier for numbers of unplanned
admissions to acute hospital care
• Numbers rising year on year despite investment in
intermediate care services
• 2003 – 9% increase in unplanned admissions
• DH imperative to reduce emergency inpatient bed days
by 5% by March 2008 (2003/04 baseline).
• DH Long term conditions strategy

5. Developing the Case Management Service
July 2004
The “EPIC” Project
12 community matrons
2005
Community Matron role mainstreamed
additional 18 community matrons
2006
Total county-wide coverage of the service
Additional 10 community matrons
2009
45 Community Matrons in post
2200 case managed patients
Use of telehealth

6. Using telehealth
•Supports self care and management for the patient
•Enables the community matron to prioritise caseload
•Adds capacity

7. Original Service Aims
Community Matron as CASE
MANAGER
Improve health
of the target Advanced healthcare practitioner
Patient & Carer Advocate
population
Reduce risk
Promote
of
Independence
admission
Strengthen Minimise time
Interfaces of spent in Case finder
care hospital
Educator
Target the Patients have
most one point of
vulnerable contact
Long term First point of contact
management
Commissioner & Coordinator of Services

8. The Challenge for Case Management:
Finding the Right Patients….
The key to success is in
accurately identifying the
right patients
Evidence shows:
• Clinician referrals do not work
• Threshold modelling e.g 65+ years plus 2 or more
admissions, do not work

9. Referrals?

10. Initial Inclusion criteria…..
Aged 75 years or over
Two or more acute admissions in previous year
Taking four or more medications

11. Current Inclusion criteria…..
Score Criteria
Adult over 18 years of age
4 Diagnosed with one or more long term condition which is unstable/unmanageable and highly
impacts on daily life
4 Has had two or more A&E visits or unplanned hospital admissions within the last 12 months
3 Is taking more than 8 medications
3 Cognitively impaired
2 Recently bereaved (major loss within past 6 months)
3 Major caregiver for someone
3 Has had major change in treatment in last 30 days
3 Lives alone
Total score of 11 or more indicates patient may be appropriate for case management

12. Case finding using PARR……
PARR:– short for 'Patients At Risk of Re-hospitalisation'
A software tool.
When an individual is admitted to hospital the tool uses
the patient’s recent admissions data (up to four years) to
calculate the likelihood of re-admission over the next 12
months.
• Implemented 3 years ago
• Cornwall NHS IT Services downloaded software and run
the tool monthly
• Lists of patients sent to Community Matrons
• CM contacts the patient and offers further assessment

13. Modelling Informs Caseload Management
• Helps set caseload boundaries & expectations
• Risk stratify according to PARR score
• Ensure fluidity between services – patient’s risk scores
will change, therefore, the service which best meets their
needs will change
• Discharge criteria
• Make use of technology
• New approach to case finding….. Do patients know they
are ‘at risk’

14. The main advantage of using
PARR
It is a robust method of case finding to ensure the
service is making the maximum difference to the most
appropriate patients
• We set threshold at 75% risk of readmission or higher
• Decreasing numbers of patients identified – on average
4 per CM per month this year

15. Beyond patient identification –
what happens next?
• Contact by a Community Matron
• Patient offered full holistic assessment including full
history, physical examination and medication review
• Personalised care plan developed with patient – includes
signs of deterioration/exacerbation and action to be taken
• Education of patient and carer
• Intensive support and monitoring
• First point of contact
• Ongoing review

16. Overcoming obstacles to using
PARR
• Pseudononymisation and de-encryption
• Numbers of patients identified
• Setting parameters – age, PARR score
• Cannot be done in isolation from primary care
PARR risk score forms a useful basis for more
investigation, but not every patient with a high risk score
is appropriate for case management

17. Where are we now?
Demonstrable savings in emergency
admissions in selected ‘ambulatory care
sensitive conditions’:
Heart Failure Flu/Pneumonia
Anaemia Epilepsy
COPD Diabetes
Hypertension Asthma
Nutrition Disorders Cellulitis
Gangrene Gastroenteritis
Other preventable infections

18. Savings on Emergency Admissions
Re ducing Expe nditure on Non- e le ctive Admissions for Ambulatory C are Se nsitive C onditions -
Savings against Expe nditure - to e nd Y2 (09/10) - by condition
£800
£600
e
ntab l
ia
£400
on
u mo n
re
on
n
Preve
Failu
fecti o
rten si
u tri ti
ren e
litis
m ia
p sy
tes
ne
a
£200
Asth m
COPD
£000
Diabe
Oth er
Flu /P
Heart
Hyp e
Cellu
Maln
Gang
Anae
Epile
Gi In
£0
er
tis
lc
ep hri
ing U
-£200
n
Bleed
Py elo
-£400
-£600

19. Reduction in Standardised Admission Rates
(SAR)

20. Plans for the future
Moving to a combined model……
• The Combined Model in Cornwall is currently being built
by Health Dialog - due for completion and delivery in
February
• Once the model is built it will be reviewed and we will
have a launch event to promote how the model can be
used
• We are looking into how the Combined Model might be
implemented in Cornwall post this initial delivery with
regular reporting
• We can see a number of uses for the Model outside of the
standard risk prediction This will enable us to tailor
services to specific needs