Reducing unplanned hospital admissions using an electronic system for sharing anticipatory care plans between primary and secondary care

Introduction: It is widely accepted that the demographic revolution currently underway means that the current model of care in Scotland is unsustainable. The population is aging rapidly. There is a corresponding rapid rise in the number of people affected by multiple long term conditions and general frailty.This abstract describes an innovative approach to systematically recording anticipatory care plans for a defined population at high risk of hospitalization and ensuring that the contents of the plan are readily available across the region in both primary and secondary care at all timesShort description of change implemented: The target population for this two year project was primarily determined by data from Public Health Intelligence (PHI). It is comprised of those individuals at the highest risk of admission to hospital according to the Scottish Patients at Risk of Readmission and Admission (SPARRA) risk prediction tool developed by PHI. This computer algorithm predicts an individual’s risk of unscheduled admission to hospital within the next 12 months.The target population of over 2,000 people consists of the top 0.25% of the population of 850,000 people living in Lothian regionIt also encompasses those individuals who attend the Emergency Department frequently and some direct clinician referrals.There are 3 groups within this population1. Younger people who attend the Emergency Department frequently (YEDFA) aged 16 to 552. People under the age of 75 with multiple long term conditions (LTC)3. Frail Elderly (FE) people over the age of 75An anticipatory care plan (ACP) is developed in collaboration with the individual person concerned following a structured interview.The contents of the ACP are made easily available 24 hours a day to all primary and secondary care staff and the ambulance service.The Key Information Summary (KIS) system developed in Scotland provides the tool necessary to share the contents of the ACP across the boundaries that currently exist between primary and secondary care.Key stakeholders involved:1. Primary care teams (127 practices) across 4 new health and social care partnerships2. Rapid Response Community-based services (6)3. Secondary care teams across 3 acute hospital sitesKey findings: One key finding is that the High Resource Individuals at greatest risk of unplanned admission to hospital identified by public health intelligence data are much more likely to live in deprived areas.Targeting clinical services towards this g