Out of hospital care
Health Navigator Proactive Health Coaching
Proactive Health Coaching is a telephone-based health coaching service which has been introduced in the Vale of York to help support patients and assist them in managing their conditions.
Using an innovative AI-based nursing service from health technology company Health Navigator, patients at risk of unplanned care attendances and admissions are identified and coached back to better health through free weekly coaching calls.
The Proactive Coaching Service is delivered by registered nurses and healthcare professionals, and is designed to offer support whilst empowering patients to take control of their health. We’ve had very positive feedback about the coaching calls from patients which are tailored to meet the needs of each individual. Time can be spent teaching, supporting patients to develop self-care skills, motivating, helping with establishing new healthcare contacts, appointment booking, and contacting their GP and signposting to other supporting services and activities.
This video made in 2017 explains:
Why Are We Implementing a Proactive Health Coaching Service?
National emergency care admissions have reached a 10-year high, with many A&E visits being identified as avoidable in the Vale of York. These attendances often occur where patients feel anxious about their health and are unaware of the alternative support mechanisms that are in place.
In such circumstances health coaching can benefit a patient by helping them to understand and manage their conditions better, know which services to access when they need support, and improve their overall quality of life.
With increasing demand on A&E and secondary care it is important that we use NHS resources wisley to support patients. The initial trial in Vale of York demonstrated a 36% reduction in A&E attendances for those patients supported by the health coaching intervention compared to those who were not.
What Are the Benefits of Proactive Health Coaching?
Patient feedback has shown that proactive health coaching can make a real difference to patients’ lives 55% of patients in the randomised control trial in Vale of York felt that that their general confidence and ability to manage their own health and healthcare increased following health coaching. The trial also resulted in a 30% increase in what is known as “patient activation”, which is a measure for a patient’s ability to take control of their own health and healthcare.
How are potential patients identified?
Patients who may be at risk of increased unplanned care attendances who may benefit from health coaching are identified through pioneering real-time artificial intelligence and predictive data analytics. The approach combines algorithms honed on tens of thousands of patient data along with manual screening to ensure that appropriate health coaching candidates are identified.
Health coaching is offered either on the ward or through a letter, with 60-70% of patients choosing to use the service.
Following the successful randomised control trial, the CCG has commissioned Health Navigator to expand the service so that an additional 1,800 patients can benefit and, it will be assessing the success of the expanded service and will extend this approach to help alleviate the increasing demand for GP appointments.
Integrating services and providing health and care closer to home
People told us that they wanted a better integration and co-ordination of services, when patients shared their opinions with us, they said ‘I want to tell my story only once’ and ‘better co-ordination of care’ this led the way to closer working with our partners in primary care, acute care and the voluntary sector to develop new approaches to integrated care.
What do we mean by integrated care?
For health, care and support to be integrated it must be person centered, coordinated and tailored to the needs and preferences of the individual, their carer and family. It means moving away from single episodes of care to a more holistic approach to health, care and support needs, that puts the needs and experiences of people at the centre of how services are organised and delivered.
How is this being approached in practice?
This work began in 2014 when we were selected to be part of the Pioneer Community for our ambitious work that focused on achieving better outcomes for patients through integrated care pilots, in York, Selby and Pocklington.
Our work featured in People helping People, Year 2 of the Pioneer Programme’s Annual Report. This work continues and developing joint approaches to better integrated care remains a priority.
York Integrated Care Team
The York Integrated Care Team (YICT) was initially established by Priory Medical Group who designed, developed and implemented the care model which was born from the views of the local community, who said they wanted fast access to care and support and to only have to tell their story once.
The YICT helps keep people out of hospital and independent for longer by working directly with each individual to see if appropriate alternative solutions can be found, offering continuous review and support to people in their home. The YICT aims to:
- Reduce avoidable hospital admissions
- Speed up safe discharge from hospital
- Enable patients to remain independent for longer
- Keep the patient at the centre of their care at all times
Following a successful trial with 55,500 patients the scheme was expanded to cover four York based practices (The Nimbuscare Alliance) and a rural Practice; totalling a population of 130,000. Subsequently, the scheme has been rapidly expanded to cover all City of York Practices totalling 207,000 patients. Feedback from patients has been really positive and the team has been highly praised for its innovative approach.
The hub has close links with Selby GP practices and North Yorkshire County Council. The aim is to support people in their home and help them be independent for longer. The team provides, short, medium and long term care:
Short term care
- First contact with local patients
- Call handling service to signpost to services
- Urgent response service
- Single point of contact for adult health and social care
- Integrated health and social care
- Rapid crisis response
Medium term care
- Care co-ordination
- Proactive hospital discharge
Long term care
Long Term Conditions care and support and case management:
- Liaison with Continuing Health Care
- Nursing home care
- End of Life care
Pocklington Integrated Care Hub
The Pocklington Integrated Care Hub is hosted by Pocklington GP Surgery. It provides a single point of access for Pocklington based patients who have a health and/or social care need focusing on people considered to be at risk of a hospital admission. The team is made up of doctors, nurses, social workers, care assistants and therapists, who tailor care to meet the persons needs. It helps keep people out of hospital by providing care, treatment and support, so that people can stay at home independently for longer. Where admission to hospital cannot be avoided, the team puts plans in place so that discharge is quicker and easier.
The aims are to promote prevention by:
- Helping patients to have a better understanding of their condition and what they can do to stay healthy.
- Working together as a team to make sure that the patient’s condition remains as stable as possible and communicating any changes or deterioration to other members of the team so that the patients’ needs are met promptly.
To offer a flexible service by:
- Using three beds in a local re-ablement facility, with flexible admission criteria to support care and help avoid emergency admissions. If the patient is admitted to hospital, plans are put in place to help earlier discharge (the Team has access to the hospital computer system and on site social care staff to support this)