NHS Trust introduces service for patients at risk of unplanned admissions

An AI-based nursing service from health technology company, Health Navigator, has been introduced across Vale of York to identify patients at risk of unplanned care attendances and admissions.

The service coaches them back to better health in a bid to help improve quality of life and reduce emergency admissions.

Health Navigator uses real-time AI and predictive data analytics to identify patients, often those with long-term conditions and who are potentially regular users of health services, who may benefit from health coaching.

Those patients from York Teaching Hospitals NHS Trust, a key partner in this initiative, are offered a referral to Health Navigator’s ‘Proactive Health Coaching’ service.

Fiona Bell, lead officer for primary care, NHS Vale of York CCG, said: “High emergency admissions are a system problem, not just the responsibility of secondary care. A lot of people go to A&E if they are feeling anxious about their health or they need reassurance. We needed to find a way to support these patients to help them understand their conditions better, make life changes which will improve their health and know which services to access when they need support.

“From the local RCT, we found that 55% of patients felt much more engaged with their care, whilst 84% of people reported an improved quality of life and having more confidence in managing their conditions. These results are really impressive and have a huge impact on patients’ everyday lives.”

Delivered by registered nurses and healthcare professionals, the service is designed to support patients with complex conditions and empower them to take control of their health.

Evidence from a local Randomised Control Trial (RCT) showed a 36% reduction in A&E attendances for those patients supported by health coaching compared to patients that had not received the intervention.

The trial also demonstrated a 30% reduction in unplanned hospital admissions and some 25% lower planned admissions for the same Vale of York CCG patients. Patient activation, a key metric for a patient’s ability to take control of their own health and healthcare, improved by more than 30%.

A wider RCT includes a total of seven NHS acute sites working with Health Navigator. Interim results from other sites are similar, in cases demonstrating up to 59% reduction in unplanned admissions for patients receiving the intervention. Results are currently being evaluated and shall be published with the NHS and the Nuffield Trust.

On the strength of the local results, NHS Vale of York CCG has already expanded the contract to 1,800 patients.

With 25-35% of urgent and emergency care being deemed avoidable and costing the NHS £6 billion annually, the project, through the RCT, has demonstrated that improvements in the patient experience can lead to reduced demand for healthcare services.

There are plans for Vale of York to become the first CCG to extend this type of service into primary care to alleviate the increasing demand for GP appointments.

Joachim Werr, Health Navigator CEO, said: “We know that 1% of the UK population accounts for 50% of non-elective bed days, so there is huge potential for new models of care such as this, based on scientific and real-world evidence of patient benefit, to reduce avoidable admissions and improve system performance.

“Vale of York has invested in a service that, most importantly, supports patients to lead healthier lives, but also has the potential for major service transformation and improvement.”


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