PredictX on risk stratification in Southend

  • techUK techUK
    Tuesday20Feb 2018
    Case studies

    Integrated intelligence can provide system improvement, improving pressure on emergency services and understanding patient flow through the health and social care system

PredictX helps Southend CCG and Southend Council reduce emergency admission

Key learning/Lessons learnt

Integrated intelligence across Health and Social Care can provide system improvement, improving pressure on emergency services and understanding patient flow through the health and social care system


Southend CCG and Southend Council in the East of England, work closely together to deliver better outcomes for patients and service users. They are jointly national pilots for Year of Care and Pioneer Integration sites. They have a challenging emergency care agenda, within Southend which became a priority as system costs were rising. It was at this stage that under the leadership of the clinical director, and the Corporate Director of Adult and Community Services decided to look for proactive solution to solve this problem

What challenge did we seek to solve?

  • Reduce emergency admissions
  • Target the right patients and service users using risk stratification
  • Continue to build upon and enhance the emerging community model
  • Engage GPs from the outset
  • Create new Multi-Disciplinary Teams and SPORs for integrated working

What did we do?

To provide better understanding of the individual patient and service user journey, PredictX was commissioned by the CCG and Southend Borough Council to implement a solution. PredictX provides a dynamic visual overview of the patient and service user journey allowing the new Multi-Disciplinary Teams to review cohorts of older people who in a one year period had attended A&E and had subsequently been admitted eight times to a hospital bed in a one year period.

The CCGs support all the local GPs in reviewing this information at practice level. Using Care and Health, the community geriatrician, community matrons, social workers and others, developed a range of criteria to generate reports and dynamic dashboards on identified patients.

This approach has the full backing of the CCG Board and Southend Borough Council and community services and there is a shared vision and ambition to improve the services and outcomes.

Barriers Sharing data and collaboration across departments could have been an issue but a culture of strong communication helped prevent the project from going off track.

Outcomes achieved

The area is beginning to see a reduction in short stay admissions, and reduction in admissions from nursing and residential homes as well as an increase in the volume of GP referrals to the range of alternative community schemes, through the single point of referral (SPOR).

Each practice now runs a monthly MDT meeting chaired by a GP and case manage a minimum of 15 patients a month, focussing on those identified as high risk of acute admissions, using risk stratification.

Future plans

As we develop our future roadmap we are collaberation with Southend to develop product focused on DTOC and Childrens Data.

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