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PACT: hospital care planning for the top 0.25% population at risk of attending hospital in Edinburgh, Scotland

Authors:

Wojtek Wojcik ,

Annette Cosgrove,

Joyce Follan,

Eleanor Halloran,

James Marple,

Catherine Moar,

Werner Pretorius,

Robby Steel

Abstract

Introduction: PACT, a novel anticipatory care planning project offers a service to patients prospectively identified as at risk of attending hospital by a population-level algorithm.

Description: Anticipatory care planning is used to assist unscheduled care in the secondary care setting and shared with primary care. The top 0.25% of the local population (Edinburgh, Scotland) is identified by an algorithm (SPARRA) and hospital attendance data. A team including nurses, a primary care physician and liaison psychiatrists deliver the intervention, with the resulting care plan held by the patient, shared with primary care, and uploaded to the hospital electronic record as an alert.

Key Finding/Progress Report: Interim data reported. Patients with end-stage illness, complex morbidity, communication factors causing frustration in unscheduled care, and medically unexplained symptoms may benefit the most. Information technology barriers between primary and secondary care continue to be an obstacle to improving care further. Secondary care based services may assist especially in complex cases where multi-specialty involvement is common or communication problems arise. Positive feedback from both patients and hospital clinicians.

Highlights: Local Case Studies and examples of significant impact on healthcare utilisation with associated savings and patient benefit.

Conclusion: Trans-specialty services nested within secondary care can assist the coordination of care for patients at risk of attending frequently. A prospective, algorithm-based approach to identifying cases can be usefully implemented.

How to Cite: Wojcik W, Cosgrove A, Follan J, Halloran E, Marple J, Moar C, et al.. PACT: hospital care planning for the top 0.25% population at risk of attending hospital in Edinburgh, Scotland. International Journal of Integrated Care. 2016;16(6):A381. DOI: http://doi.org/10.5334/ijic.2929
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Published on 16 Dec 2016.

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