Willows Health is a group of seven Leicestershire practices with over 43,000 patients and is part of the Aegis Primary Care Network. The GPs’ proactive approach towards population health management (PHM) includes identifying patients potentially nearing the end of their life to ensure they are given appropriate care and support. However, they have struggled to identify this population in a comprehensive manner. An audit carried out by the team identified that half of patients who had died in the previous six months did not have a care plan.
Action
MLCSU’s population health analytics platform, Aristotle Xi, gives users rapid access to an online suite of business intelligence tools and reports to support PHM. It is being used to give the clinicians a Mortality Risk Score (MRS) – a new algorithm generated from outputs of the Johns Hopkins Adjusted Clinical Group (ACG®) System. This enabled them to identify a large number of patients who had not previously been included on the palliative care register.
Once the list was created, it was given to members of the clinical team so they could undertake a review of patients on the list to determine whether they would benefit from a palliative care plan and to determine the urgency of such a process.
Impact
This innovative work has enhanced and supported Willows Health’s care planning work with palliative care patients and enabled them to provide patient-centred reviews and end-of-life care plans for those with higher levels of risk. These have helped reduce hospital attendances and length of stays.
Aristotle Xi and the ACG System support the group’s clinical programme, enabling proactive assessments, enhancing the quality and experience of care through optimisation of long-term conditions, undertaking medication reviews, signposting to additional support systems and exploration of patients’ care preferences and best interests in this context.
Willows Health GPs are now able to offer the right support to a greater number of patients who are nearing the end of their life.