Cornwall and the Isles of Scilly has a unique context where its acute hospital serves roughly 50,000 patients, with 2,500 alone on another island. Whilst the Neighbourhood Teams have been working on care in the community for years, last year they formally divided the area into 16 Neighbourhood Teams and gave each one a brief.
This population-health based approach gave each team the data around frailty, emergency department admissions, end of life care etc for their neighbourhood populations. Using this data each Neighbourhood Team have been empowered to design and deliver a care plan in their areas, therefore enabling them to provide proactive care to patients before they need to attend a hospital. This in turn frees up more resource for reactive care within the hospital setting.
A second approach uses a risk stratification AI tool, which gives the Neighbourhood Teams an indication of the people most likely to be admitted to hospital. Teams are then able to intervene before an admission, again saving demand on the hospital. So far of all those identified by the AI tool, one person has been admitted to hospital and that was just for a day.
“We’ve given them (Neighbourhood Teams) a population health-based approach to say ‘this is your population and this is the activity your population generates, could you use it to reduce emergency admissions, ED attendances and length of stay?’’
“Once given, Neighbourhood Teams own it and they’re empowered to design and deliver that. That’s a proactive model. Key to this is a risk stratification approach. Using an AI tool which gives us an indication of the people most likely to be admitted to hospital and do something about it.
“That’s been really impactful!”
- Chris Reid, Chief Medical Officer Cornwall and Isles of Scilly ICB and Exec SRO for Neighbourhood Teams
