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Self Care Week: Identifying and coaching high-need patients at risk of going to A&E

Posted: 20th November 2020

For our final day of Self Care Week coverage we continue to showcase some of the innovations and partners we’re working with who are empowering patients to take a more active role in managing their own health. In this article, we take a look at HN, an innovator company that has developed an algorithm to identify high-need, high-cost patients, who are at risk of going to A&E. They then provide a digitally enabled clinical coaching programme, which helps patients to better understand their condition(s) and empowers them to engage in self-care, therefore reducing their need for NHS resources.

The HN story began with their founder Dr Joachim Werr, who is an NHS Innovation Accelerator Fellow and was previously an emergency physician in Stockholm. Werr observed that the same patients would regularly attend his A&E department and so, in 2010, as part of his PhD in Physiology at Sweden’s Karolinska Medical Institute, he and his fellow researchers developed a predictive algorithm to track patients and assess their risk of returning to A&E. He then turned his attention to supporting the identified patients through tele-coaching. In 2015, the model was introduced to the UK.

HN Clinical Coaching CARE is a six-month, high intensity clinical coaching and navigation intervention programme that uses Artificial Intelligence (AI) guided case-finding, enabling the identification of patients with long-term conditions, who are at high risk of unplanned hospital care. HN’s predictive algorithm has well-tested and robust information governance, complying fully with GDPR. HN build effective algorithms that are ethical, fair and support reducing health inequalities.

Their randomised controlled trial with the Nuffield Trust, demonstrated a return-on-investment (ROI) of 200-300% for their NHS partners. This was in addition to the value created in terms of improved patient reported outcome metrics (PROMS).

With the onset of the COVID-19 pandemic, HN’s partners in the NHS communicated a new need based around HN’s scientifically evidenced service. Through brainstorming sessions with the HN clinical and analytical teams, they co-created HN COVID-19 CARE. The new service is delivered by healthcare professionals, who complete a holistic assessment of the referred patient.

The patient is monitored, coached and supported by telephone and/or video until they are ready for discharge. The service is COVID-secure and provides assurance to patients and clinicians, without the need for a face-to-face interaction. A personalised healthcare plan is provided, encouraging patients to engage in self-care and make positive lifestyle choices. This ultimately leads to patients reducing their need of NHS services and creating sustainable healthcare for everyone.

Yorkshire & Humber AHSN are currently working with HN and the three Integrated Care Systems in our region to see how this model could be replicated.

Find out more about HN

Read the Vale of York’s Personalised Care Group system case study

Read about the HN AI trial