Use quantitative and qualitative insights to co-design holistic, person-centred solutions, enabling flexible, integrated support that wraps around the person.
The primary focus of High Impact Change Model: reducing preventable admissions is to reduce admissions to hospitals by remaining in or returning to the community.
B1: Group at risk individuals into cohorts which allow clear ownership of support and case management by operational teams
- Re-group identified high-risk individuals into cohorts, to tailor delivery in a practical manner. Example cohorts are provided in the Suggested Actions section below.
- Map cohorts against e.g. Multidisciplinary Teams (MDTs) or existing services to ensure clear responsibilities for admission avoidance support.
- Be clear on case management responsibilities to prevent duplication where individuals belong to multiple cohorts, or lack of coverage of other high risk individuals outside of classic cohorts.
B2: Use a combination of quantitative and qualitative inputs to design the right holistic solutions
- Focus on providing holistic support to high-risk individuals, as they often face multiple interconnected issues rather than isolated ones.
- Incorporate qualitative insights and co-design solutions - considering what matters to the individual, and the perspectives of their family and carers.
- Conduct case reviews with a multi-disciplinary team to determine the ideal support for an individual and the barriers to achieving it.
B3: Flexible support able to wrap around the whole person
- Diverse support options should be made available, ensuring that both staff and the individual receiving support are aware of all available options to provide more personalised and comprehensive support.
- Take into account factors beyond a person's health needs, for example risk of carer ill health or breakdown, which significantly contributes to avoidable hospital admissions among frail elderly individuals. Does your risk assessment and intervention strategy address these wider issues?
Identifying people at risk: suggested actions