small
interventions
in large numbers
of
patients
Small innovations in primary care
Summary
There’s rising patient demand, but reducing supply of clinicians. Consequently, it’s difficult to provide proactive care in this environment. But, we think we have found a way to do this.
Little nudges
in the form of small and large patient group consultations. Small groups of 7 people or larger groups of up to 70 people. Interventions were generic and focused on wellness or specific conditions such as diabetes or atrial fibrillation.
Resulted in
reduction in demand from patients with higher health needs (Electronic Frailty Index).
Reduced appointments by 1,700 p.a.
However no increase in patient knowledge, skills and confidence of their own health (measured using PAM Score). We think this is because interventions need to be more customised.
Primary care has always had an aptitude for innovation – there has never been a more important time to accelerate this.
Demand for appointments is increasing yet simultaneously, the supply of staff is reducing. In this article, we will outline some of our experiences of how a model to be proactive can actually result in a reduction in demand. We presented this work at the Royal College of GPs conference in 2018. The situation has probably got worse after COVID and is even more relevant now. How can innovation in primary care help to overcome these challenges?
Predict demand so that primary care can innovate
We used the Electronic Frailty Index (EFI), which is a tool to identify those who are unwell and likely to be ill in the near future. It uses the existing information within the electronic health care record to identify populations of people who may be living with varying degrees of frailty.
The EFI is an absolute number where 1 is the maximum – written as a percentage. So 1 is 100% and 0.75 is 75%. Patients were classified 3 EFI groups, severe, moderate and mild EFIm using the percentage ranged 75-90% (mild), 90-95% (moderate) and 95-100% for severe EFI.
Characteristics of those likely to be ill in the future
Age
Interestingly, 50% of patients with moderate EFI were under the age of 50, so, it’s not just the older patients we need to support. Some of this younger cohort did not have chronic diseases.
Marital status
Marriage or civil partnership is a protective factor. Divorcees or widow/ers had higher EFI scores.
Employment
The data shows that unemployment or retirement is associated with a higher EFI score – associated with higher levels of ill health.
Small interventions for large numbers of patients
In fact, we can support groups with lower EFI scores by making small interventions for large number of people. Indeed we promoted system-wide self-care sessions in small and large groups, over a 2 year period.
Overall appointments increased by 10,000/year, however, the percentage of appointments taken by the 3 EFI groups (which form 25% of the practice population) reduced from 80% to 58% which equates to a reduction of 1,700 appointments a year.We outlined these results in our poster for the Royal College General Practitioners Conference in 2018.
the percentage of appointments taken by the 3 EFI groups (which form 25% of the practice population) reduced from 80% to 58% which equates to a reduction of 1,700 appointments a year
Understanding patient behaviour
We also tried to measure patient behaviour. For this, we used a validated tool, Patient Activation Measure (PAM). This is a questionnaire which evaluates patients’ perception of their knowledge, skills and confidence in their own health. It ranges from PAM levels 1 to 4 where patients with level 1 have low levels of knowledge, skills and confidence in their own health. Significantly, high levels of patient activation result in lower levels of demand for GP appointments.
We carried out PAM assessments of 300 patients, we found that our generic interventions over the last few years made no impact on patient PAM levels or A&E attendances. Achieving an impact on demand is likely to follow from interventions tailored to the knowledge skills and confidence of patients.
we found that our generic interventions over the last few years made no impact on patient PAM levels or A&E attendances.
Coaching to support health behaviour
We feel goal, not disease, based clinics are most effective. Staff should have time to support the community and groups of patients. Interventions could, for example, be in the form of proactive calls, small and large group events which could be online or in person. Innovation in primary care isn’t always about the use of technology. It’s about using the right words at the right time.
The key is different PAM level groups have different needs. As a result, we designed our diet and exercise interventions. These were to support change in behaviour and called ‘on your marks’, ‘get set’, ‘go’ and finally ‘keep it up’. Each had different messages to support the needs of the person at their particular point in behavioural change. We feel small interventions which are matched appropriately can support behaviour changes and reduce demand on the practice and A&E. Self-care in short creates time for the practice to provide proactive care.
To summarise, innovation in primary care is understanding the problem and working with patients to explore new ways to complement the existing models of care.
We feel small interventions which are matched appropriately can support behaviour changes and reduce demand on the practice and A&E.
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