Care Outside of Hospital

We have worked with customers to develop comprehensive strategic and operational plans to provide easy access to high quality and responsive primary and community care. We have developed, aligned and implemented simplified plans in urgent, unscheduled and planned care pathways. We have taken these strategies and developed service models in partnership with customers, to deliver sustainable change in the provision of care outside of hospital, improving outcomes for patients. We are supporting commissioners in identifying solutions to the provision of care outside of hospital, to enable patients to spend only the appropriate time in hospital when they are admitted.

Our delivery focus provides tangible outcomes for our clients and patients, including:

  • high quality care delivered closer to home
  • reduction in hospital emergency care
  • reduction in length of stay in hospital
  • new processes to proactively manage admission and discharge
  • efficiency savings
  • collaboration of health and social care organisations to build a whole system approach to care
  • health and social care, including Public Health organisations, to build a whole system approach to care.

Attain brings together clinical leaders, commissioning leaders, stakeholders and patients in our co-development approach. Our experience shows that this method is very successful in developing and implementing improved patient services. Our team’s expertise spans the whole spectrum of care, including community services. Attain is uniquely focused on transformational commissioning, delivering a range of specialist services to support improvements to patient care, helping implement new models of care to ensure that patients get the care that was intended.

care outside of hospital

Case study – Improving long term conditions management

Our team has worked with commissioners across London and the East Midlands on Care Outside of Hospital. In one particular example in London, members’ analysis of key data showed that there was a significant difference between the high levels of unscheduled care activity for long term conditions, compared with an apparently low prevalence shown on GP QOF registers. A project was delivered to completely redesign four patient pathways. Key to the success of the project was strong clinical and user engagement to generate buy in from clinicians providing the service and ensure the new service met users’ expectations. Each pathway was redesigned by a team led by a GP and secondary care consultant to ensure an appropriate balance between primary and acute care. Clinical engagement was so effective that significantly more GPs wanted to be involved than available roles in the project.

Outcomes

  • In the first full year of these pathways being in place, unscheduled care expenditure across the four pathways was reduced by £1.5m
  • Providing GPs with real time monitoring dashboards on their desktops so they can identify hospitalisation in each of the four pathways as well as patients at risk of hospitalisation
  • Multi-disciplinary teams including Social Care staff covering five to seven practices targeting patients with these four long term conditions
  • Outcome based specifications for the integrated community service teams that would manage the pathways
  • Implementation and use of a risk stratification model utilising a mix of primary care and SUS data to assess the ongoing risk for hospitalisation
  • Support for GPs to identify and address at risk patients where prevalence patterns did not reflect levels of hospitalisation