Enabling the use of information locally Improving local access to national data Navigating the information landscape

The Local Approach Making national data more accessible Utilising local data Ability to join up local and national information Focusing on local needs and priorities Sharing learning

Linked Health and Social care file at an individual service user level Integrated Data CHI Linked Health and Social care file at an individual service user level Intermediate Care SIMD Outpatients A&E Deaths Inpatients Community Hospitals @ Home Day cases SPARRA Social Care Prescribing Housing and Homeless Age/gender Partnership Access Via secure platform £ Linked File 3

Mr Smith=£60k (0.01%) Practice X 131= £4.5m (1.3%) Locality A 335=£13.5m Partnership 7 2,600 =£90m (2.0%) Scotland 103,839=£2.5bn (1.9%)

Pathway for Mr Smith Died March 24th 2 x Em admission (21days; £6,435) J S O N D F Died March 24th 2 x Em admission (21days; £6,435) Delayed Discharge Em admission (74 days; £17,128) Care home stay (207days; £30,000) Pl admission (5days; £2,259) Em admission (5 days; £1,615) A&E Attendance (£97) Emergency Admission Planned admission Outpatient Attendance (£156) Day case (£152) Care home resident

Why link Social Care Information to Health? Access to services How: Urban rural analysis of health & home care Understand users of both health and home care How: Locality profiling of health & home care users, begin to understand care needs & complexities Known delayed discharges problem – pre and post admission? How: Linking social care data to look for redesign opportunities through bottlenecks, delays in providing services for post acute care needs HRI pathways – repeat unplanned admissions How: Look at pathways of HRIs with multiple unplanned admissions, is social care present or missing, opportunity for redesign

Frequent A&E Attendance Did you know... In one area, among the top 100 most frequent attenders, the average number of A&E attendances was 18 The average cost per person of the frequent attenders was £18k (just over £1k for other service users)

What are we doing? ISD have been working with a number of partnerships to identify those that frequently attend A&E Linking this data to other national datasets has enabled partnerships to consider what healthcare resources are utilised by this cohort Partnerships can build a greater understanding of demand and ensure that similar patients have access to and are using appropriate services across health and social care This will enable people to receive the best care and outcomes possible and improve their quality of life

What could change? LIST can help partnerships to free-up and re-direct resources by identifying the relevant cohort for community interventions A greater understanding of demand Targeted services to improve patient outcomes National intelligence and local context - working with local teams on the ground has fostered new thinking

Homelessness Did you know... 30,000 people were assessed as homeless last year by their local authority A homeless person’s estimated cost is between £24-30,000 per year

What are we doing? The Local Intelligence Support Team (LIST) have been working with local data to examine the needs of people who have applied for homeless status, linking homelessness data to 10 national data sources. Undertaken an assessment of the healthcare needs of the homeless population, for example The psychiatric admission rate in those that were homeless was 10 times the rate in comparison to the wider population A&E attendances due to self harm were 20 times higher

What could change? Providing powerful evidence to help reshape future service provision for people that are homeless Health and homelessness services will work better together to ensure that needs are identified and addressed as quickly as possible People will be directed to the care that they need and become more aware of the health and community services available to them This will result in improved health outcomes and a better quality of life for those that are homeless

Community Alarms Innovative linkage of hospital and community alarms data to assess the results of a Community Alarms pilot Provide real world evidence of community alarm effectiveness Reducing burden on A&E departments and ambulance service Information gathering to support a wider review of out of hours services

Third Sector Collaborations with third sector organisations to improve understanding of how the Third Sector contributes to person centred, integrated mental health care. This project aims to explore the use of data available from the Third Sector Two areas have been selected as pilot sites to explore the impact of third sector provision on Mental Health Achieving better outcomes for individuals and communities

Readmissions Reduction in Emergency Admissions by looking at longitudinal trends in readmission rates and mean length of stay Part of working group to look at reducing emergency admissions Could the hospital seek to avoid some readmissions by looking at alternative methods of supporting particular patient cohorts Average LoS has been coming down but readmissions are still on the rise in at least some patient groups

Locality Profiling Locality based workbooks and profiles for locality managers for locality planning One example - A&E attendances by Locality cut by age group, flow type and whether the individual attended in or out of hours (other information also available) Tailored to colleagues in the partnerships to provide locality information that they may not have access to   Easy access information, PDF friendly, with short summary and attached notes explaining the key points and any important caveats

What are the challenges? What can we do? What could change?