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Table 1 Summary of the case studies

From: Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network

Stage Intervention Description
Pre-Emergency Department Patient At Risk of Readmission (PARR) tool and Combined Predictive Model Tool providing a risk score, which predicts risk of hospitalisation in upcoming 12 months. Uses data from inpatient and census data but Combined Predictive Model can additionally combine outpatient, emergency department and GP practice data. Links data confidentially.
  Adjusted Clinical Groups predictive model (ACG-PM) Predictive modelling tool predicting risk of hospitalisation and where interventions (i.e. active case management) will have the greatest effect. Uses multiple data from primary care, Outpatient and ED data, including demographics, co-morbidities, and prescribing. Whole populations are modelled including non-health care users.
  Virtual Wards Multidisciplinary Team (MDT) managing patients at high predicted risk in their own home with encouragement of self-management. MDT involves GPs, community matrons, ward clerks, district nurses, palliative care, pharmacist, Social Services, etc. Consists of initial assessment, agreed care plan and goals, regular contact and weekly MDT meetings.
  Community Matrons Community-based case management of high-intensity health care users by senior nurses. Often work within the MDT of virtual wards.
During Emergency Department In-reach nurse As part of the Community In-Reach Team (CIRT), in-reach nurses' role is to facilitate discharge, avoid admission, link to community services, and speed investigations for suitable patients in emergency department.
  Consultant GP Consultant GP based in emergency department to identify suitable patients and facilitate discharge. Techniques used include reassurance of staff/patient/family, medication adjustments, liaison with patient's GP, referrals to alternative care pathways, and gaining specialty advice.
Post-Emergency Department Appropriateness Evaluation Protocol (AEP) Validated audit tool used on notes of admitted patients to determine appropriateness of their admission and stay in acute bed. Feedback is then given to improve practice.