Change 2: Target and tailor interventions and support for those most at risk

This change supports Goal 1: Prevent crisis.

Making it Real statements

I feel safe and am supported to understand and manage any risks."

We work with people to manage risks by thinking creatively about options for safe solutions that enable people to do things that matter to them."

Tips for success

• Having formed an integrated view of those at high risk of preventable admissions, maintain and use local lists and registers of at-risk cohorts to offer regular timely screenings and interventions. Take account of when seasonal or time-based responses may be needed, such as ‘flu or months when falls-related admissions increase.
• Make the use of screening tools, such as the Frailty Index, part of the pathway used to identify individuals at risk. Support more integrated care for people living with frailty by developing enriched summary care records.
• Provide a single point of access for health and care staff to make referrals for community interventions. Where possible these should be trusted referrals which lead straight to intervention, to avoid the person repeating their situation and so that they can be coordinated around the individual and their family and/or carer(s).
• Ensure collaboration between pharmacists and other community services to support medicine reconciliation and review.
• Early use of technological interventions and solutions, where appropriate, can promote independence for longer and so delay or remove the need for community services, such as homecare, altogether. Develop a process to introduce assistive living equipment and digital tools to support self-management as soon as possible after the need is identified.
• Use telehealth and telecare to support the treatment and monitoring of people at home to anticipate potential problems or crises. Embed the use of digital technology, where appropriate, such as remote monitoring and video consultations, across the pathway from home to hospital or care home, and then the transition back to community.
• Ensure that housing needs are considered. Ready access to an appropriate range of housing related support can help people stay in their own home as well as support those with no or inappropriate housing.
• The NHS Enhanced Healthcare in Care Homes framework sets out the key actions to support health and wellbeing for care home residents.
• Where telecare is used as a reablement intervention, consider expanding this offer to include other types of telehealth digital monitoring devices. Use trusted assessment to prevent delays in assessment. Reablement can be used as a preventative intervention.
• Unlocking the preventative benefits of care technology requires a good understanding of the digital and data capabilities of your local care technology offer. What is your approach to using data from devices to drive real-time decision making or to anticipate and prevent crises? How will the data collected from technology be analysed and used to inform care planning and reviews or reassessments?
• Ensure that care plans for those at the highest risk include regular prompts for timely screenings and other forms of preventive care. Consider also whether a safeguarding plan is required. 

Examples of emerging and developing practice

• Following two avoidable deaths of people with learning disabilities Camden introduced a population health management approach to avoiding physical health hospital admissions for people with learning disabilities. This led to the implementation of ‘Significant 7+’ which has increased the confidence of supported living provider staff to take early action including saving a life through early identification of sepsis and reducing 999 calls. LGA, April 2021
• ‘How (I try!) to avoid a hospital admission for someone with frailty’, A blog from a community geriatric team doctor working in West Kent’s Home Treatment Service, British Geriatric Society, March 2018
• Increasing uptake of assistive technology through behavioural insights: Knowsley Metropolitan Borough Council increased the use of assistive technology in the home by targeting groups of residents who might benefit – those with blue badges and those with assisted bin collections, LGA, February 2019
• Health Call Digital Care Home: Durham has taken a partnership approach to rolling out technology, including remote monitoring across older people care homes, extra care and two specialist learning disabilities homes, which has contributed to a reduction of two hospital admissions per care home per month, LGA, June 2020.

Supporting materials