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Aberdeenshire Staywell - Reducing hospital admissions and bed days for patients with long term conditions

CHALLENGE
In common with all its NHS counterparts throughout the UK, Aberdeenshire CHP has the challenge of reducing unscheduled hospital admissions and bed days for patients within its community. It has developed a new anticipatory care programme, particularly focused on patients with long term conditions such as COPD. In putting together this programme, the team realised it lacked a suitable self care education tool that could be widely and cost-effectively deployed.

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SOLUTION
Two years ago, Aberdeenshire licensed and deployed Intouch’s “Staywell” Self Care Education Programme around a number of its GP practices, district nurses, re-hab teams and community hospital. Patients are invited to participate online or on paper. The initial focus has been on COPD, diabetes and health of the elderly.

The CHP team have been particularly keen to measure the impact of Staywell on hospital admissions and bed days, and also to see how it can increase productivity in primary care.

RESULTS
Although it is still very early days in the collation of results, an initial study of a small group of patients suggests that Staywell may contribute directly to the reduction of admissions and bed days amongst patients with COPD. As far as possible, the impact of Staywell has been separated out from other components of the anticipatory care programme. The CHP estimate that thanks to Staywell, on average, 8 bed days per-patient-tracked have been saved with a value per day of £612 – a total of £4896 per patient. A more robust data set should be available by the turn of the year.

The adoption of Staywell Diabetes has resulted in a QoF-related scheme to improve productivity in primary care. The strategy is that any diabetes patient who completes the Staywell self-management knowledge audit at least twice in a year, and who achieves what is defined as an acceptably good score, will earn QoF points for the practice WITHOUT the patient having to attend surgery for an annual health check.

The nurse time saved in this way is then used with those patients who score badly in regard to their self care competence and who are therefore at most risk of requiring crisis care.