1. SPARRA Lorna Jackson Head of Programme Long Term Conditions Information Programme

2. What is SPARRA? Scottish Patients At Risk of Readmission and Admission SPARRA is an algorithm for predicting a patient’s risk of emergency inpatient admission to an acute hospital in a particular year

3. SPARRA the ISD service Risk Scores generated for all relevant patients (SMR1) Customers at Board, CHP & practice level receiving data relating to their populations Aggregated –Distribution of risk scores –Characteristics of risk categories Patient-level –Patient listing with ID, risk scores & factor values –Threshold option Quarterly updates –NHS email/encrypted email/CD/Navigator

4. SPARRA – Summary of Current Usage SPARRA is being used to identify and selects patients suitable for Further case management or coordination (dedicated case managers or otherwise) GP-lead Local Enhanced Services –Diseases-specific (eg COPD) or more generic –Further assessment/reviews/referral –Anticipatory Care/Self- Management Plans –Sharing of information eg A&E, Out of Hours

5. Example – North Ayrshire CHP Enhanced Service for COPD /LTC patients Main Features GP and DN involvement SPARRA scores for high-risk patients shared with CHP –Practice-based patient registers (>60% risk or >50% & COPD) Assessment (including SSA)/Multi-disciplinary review of care COPD –Individualised exacerbation self-management plan –Assessment/referral to pulmonary rehabilitation –Significant-event analysis Flagging and sharing of information with NHS24, ADOC, A&E –Alerts on supporting IT systems/Identification of Case manager

6. Use of SPARRA – key points SPARRA can be used to identify a cohort of patients with a high risk of further admission –Often these patients have already entered a cycle of repeat admissions –Further admissions for some may not be preventable –Patients have multiple LTCs –Some are close to death & so their requirements are different –Should always be linked and used in conjunction with local data/intelligence

7. Development of SPARRA Short-term New ‘All ages’ algorithm developed –Original modelling work repeated/improved on a recent national ‘all-ages’ cohort –Still based on patients hospitalisation history / largely same factors –Will identify 2 x high risk patients (28% more 65+) –To become operational January 2009 –Functionality to distinguish those ‘newly’ identified from ‘previous’ cohort Longer-term A tool applicable to a wider cohort (eg entire registered population) –Incorporation of other risk factors/datasets eg primary care, prescribing Big challenges are finding suitable datasets –Nationally comprehensive –Real-time –Data-sharing issues