Integrated health and social care services across St Helens
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Population Health Social Care
The cost of social care provision continues to rise. A number of factors contribute to this including a cost of living crisis, high patient waiting list numbers and people living longer with increased needs. Preventative care can always be delivered at a much lower cost than to those in crisis but segmenting and identifying those with imminent increased support needs can feel like searching for a "needle in a haystack". With Graphnet's Population Health tool, social care teams are alerted to individuals or groups who are likely to be imminently part of the social care system in a crisis situation. This makes planning budgets, people and other resources simpler.
Our unique partnership with System C, providers of the market leading Liquidlogic social care system, enables seamless integration between shared care and social care systems. Our CIPHA platform supports a number of ground breaking projects through use of population health data to identify those with needs currently not visible to social care teams. By identifying cohorts that are vulnerable but not yet meeting social care thresholds, councils can proactively intervene to deliver often low level services to prevent hospital stays, residential care and any deterioration in health and living conditions.
How does Population Health Support Social Care?
Graphnet’s population health platform offers many ways in which to identify those most in need of social care support and intervention. Here, we examine just some scenarios where population health data can be used to prevent further deterioration, support those in need and act quickly to maximise the best outcomes.
Population Health & Social Care Use Case Examples
1. Preparation for Adulthood
Every young person needs support in preparation for adulthood and whilst most do that simply with the universal circle of support that is on offer to them, a small group of young people who are in complex situations don’t get what they need to enter the adult world and are at risk of falling through the net. In this scenario, the young person often ends up in crisis with urgent and last-minute care required, which is high risk, traumatising and high cost.
Young people who are already known to social care, community or mental health teams often experience issues when transitioning to adulthood, so identifying those individuals is particularly important. A dashboard using population health data to identify young adults most in need of multi-agency intervention for these often-overwhelmed teams can be invaluable. Using population health data, young adults with disabilities, mental health issues or a disjointed family network who may have previously been unknown or only known to a single service, are located and a multi-agency care plan and associated interventions can be implemented.
2. Section 117 Aftercare
Section 117 aftercare is the free help and support provided by the NHS and social services following a stay in hospital under certain sections of the Mental Health Act. Section 117 patients are a legal responsibility for all local authorities and partners. As such, each organisation maintains an internal record of individuals registered with a section 117 legal status. However, disparate IT systems can make it challenging for teams to see a consolidated view of a patient. This can lead to discrepancies appearing across systems resulting in a disjointed perspective on the section 117 patient cohort.
The section 117 dashboard is an analytical solution which allows many councils to upload a list of people with Section 117 requirements to a secure data platform, which only approved council users can access. This can be done as frequently as needed. Data from each council is joined together and presented in a dashboard. Councils can access the data which they have supplied, which is augmented with flags which indicate if a person in their upload has a section 117 in another council’s dataset.
Access to the dashboard is secured using row level security and only accessible to approved and authorised users.
The dashboard facilitates information sharing, strengthens data quality and promotes a multi-agency approach to section 117 aftercare.
3. Early intervention
Adult social care is under incredible pressure and funding by government does not fully fit the demand. Pressures include high levels of unmet or under-met care needs, delays in accessing support and catastrophic care costs, high levels of unpaid care and the overall financial sustainability of care providers who have workforce pressures.
Identifying in advance those who may need social care support and intervening before they need significant, or high-cost care is one way to help ease pressures on social care teams.
The model has been developed with System C for their leading social care system, Liquidlogic and uses Graphnet Population Health data to predict whether somebody will be referred to social care in the next 12 months. The model only works on adults and excludes anybody currently with an open referral to social care and have not declined the service in the past year.
Early identification of patients who may have unmet of forthcoming needs can reduce the need for social care in vulnerable populations in the following ways:
- Increase independence through activating citizens in community-based services, encouraging effective self-care.
- Improve quality of life and wellbeing for potential service users.
- Reduce social isolation.
- Delay and reduce needs for care and support, potentially reducing the social care costs.
