By targeting the right interventions at the right people before they are admitted, the deterioration of their conditions may be prevented or slowed down. In addition, because the model uses a combination of primary and secondary care data sources, it can also categorise people with long-term conditions according to their risk of hospital admission, enabling organisations to implement different interventions and care pathways according to varying needs.
The Combined Model will assist community matrons and other case managers, who are responsible for planning and co-ordinating patient care and ensuring that health and social care teams take a joined-up approach. UK Health Minister Rosie Winterton stated: "Our population is getting older and more of us are living with an illness or condition, which means huge increases in demand on health and social care services. Many PCTs are adopting case-management approaches as a means of ensuring the most vulnerable people receive fully joined-up health and social care and have person-centred care planning."
The King's Fund and their partners Health Dialog and New York University were commissioned by the Department of Health and the strategic health authorities in 2005 to develop a number of techniques to accurately predict future frequent users of hospital services. The first tool, the highly successful Patients at Risk of Re-hospitalisation (PARR) was launched last year, and is actively being used by many PCTs.
The Combined Model builds on learning from PARR but draws on a much larger and richer data source. Pilot sites have shown the Combined Model to be an effective tool for delivering better care for people with long-term conditions and helping to reach and sustain the target reductions in emergency bed days.
King's Fund chief executive Niall Dickson stated: "Providing better care for people with long-term conditions is one of the great challenges in modern health care. This new model will arm health care professionals with the information they need to target patients who face a much greater risk of ending up in hospital if their conditions are not managed effectively in the community."
"Previous techniques only allowed us to identify patients who had already been admitted to hospital on at least one occasion. However, this model allows us to go beyond this group to identify and provide better care for the vast numbers of people whose conditions are not yet at this critical stage. Helping these patients with good disease management programmes, or supporting them to self-manage, should have a great impact on their daily lives and prevent unnecessary hospital admissions", Niall Dickson explained. "For millions of people with long-term conditions this could be the start of a new and exciting era. This more sophisticated approach will be crucial not only to providing better care but also to making better use of NHS resources."
Geraint Lewis, specialist registrar at Croydon PCT, where the Combined Model was tested, stated: "The Combined Model has transformed the way we look after people in Croydon who have complex medical and social needs. By allowing us to identify individuals before they become acutely unwell, our clinicians can offer pro-active - rather than reactive - care. As the Combined Model uses routinely collected data from across the whole population, it means that this extra support can be offered to those people who will benefit the most. In this way, the Combined Model can also help to reduce health inequalities and bring care closer to people's homes."
The accurate identification of people who are predicted to be at risk of unplanned and unnecessary admission to hospital is a key element of the Department of Health's long-term conditions strategy.
The King's Fund is an independent charitable foundation working for better health, especially in London. It carries out research, policy analysis and development activities, working on its own, in partnerships, and through funding. The King's Fund is a major resource to people working in health and social care, offering leadership development programmes; conferences, seminars and workshops; publications; information and library services; and conference and meeting facilities.