PHDcic, Aetna receive Health Service Journal award for programme to create systemic change in primary care

An innovative group of GPs in the West Midlands is proving that starting small can produce big changes — and their efforts are not going unnoticed. Pathfinder Healthcare Developments cic (PHDcic) together with Aetna Health Services UK (Aetna) have secured their latest award from the Health Service Journal for a programme that aims to create systemic change in primary care. Promising early trends indicate that one of the key interventions—a nurse-led telephone care management service operated by Aetna—has yielded at least a 45% lower hospital admission rate for enrolled patients compared with a similar control group of patients not in the programme.

“The early success of this programme and the award underscore how the public and private sectors can effectively work together to meet the needs and health objectives of the UK population”

Patient satisfaction survey results for those participating in the chronic care programme have also been positive, with overall satisfaction averaging 90%. Amongst PHDcic's patients, an impressive 67 percent of those invited, or 390 people, engaged in the programme from May 2009 to September 2010.

"The early success of this programme and the award underscore how the public and private sectors can effectively work together to meet the needs and health objectives of the UK population," says Dr. Niti Pall, Chair, PHD. "It's been two years since we began redesigning our patient services. We have worked in partnership with Aetna, in a collaborative manner to restructure the way our practice delivers care to focus on value for our patients, greater patient involvement in their care, health management and cost reduction. This has been helped a great deal by the expertise that Aetna bring to the table."

The programme demonstrates one way to fight back from a devastating report published in December by the public health observatory showing that one-third of people in the West Midlands are overweight, making the region the most overweight place in Europe.

The whole system change targeted by the PHDcic-Aetna partnership is designed to tackle the increasing cost and poor health resulting from long-term, lifestyle conditions that contribute to poor health, including obesity. Work is focused on specialised interventions for people with chronic conditions; raising awareness of available health services; and developing the local health workforce to empower staff and sustain change.

"We are honoured to have received the Health Service Journal award with Pathfinder and delighted with the growing success of our care management programme. We are hopeful that our continued expansion of the programme will validate these early results," said Vincent Sai, Managing Director, Aetna Health Services UK. "Patients are at the core of the service. The goal is to inspire healthy behaviours through motivational coaching and support by our nurses to empower patients to make sustainable changes and manage their health conditions. PHDcic has been an effective and innovative change maker in the UK and proven to be an invaluable partner in piloting this ground-breaking programme."

PHDcic and Aetna worked together to develop a bespoke model appropriate for the UK by translating some of Aetna's extensive experience in data analytics and predictive modelling technology, which determines likelihood to be admitted to hospital or to have future complications due to health status. In this UK model, patients are identified for various interventions—from high intensity, one-on-one care management support to lower-intensity group consultations that provide peer support or online resources.

Aetna's care management programme is a telephone-based support service for patients who have two or more long term conditions. Aetna nurses proactively reach out to patients to help coordinate their personal care needs and support adherence to medication and GP care instructions. Early evaluation of the programme indicates that care management is likely to produce a significant reduction in medical costs through better preventive care and patient adherence to doctors' instructions

"Our goal is to provide real and effective care that improves health outcomes for all of our patients," said Dr. Pall. "We want to focus on the sickest and highest users of services and also recognise the critical need to engage with patients early on to curb the growing trend of unhealthiness and the rising costs of treatment."

Underpinning these patient initiatives was money raised by PHDcic to invest in strong medical mentoring, supervision and performance management to develop a new workforce model to deliver a changed service. Ultimately this work has underscored how primary care can lead to health improvements that reduce costly and unnecessary urgent care usage through proactive and preventative care. Importantly it has enabled PHDcic practices to be fit for purpose to take on GP commissioning.

PHDcic and Aetna are currently working with additional GP surgeries in Sandwell to expand the programme to validate these early results. Aetna also provides commissioning support including risk stratification and telephone care management to Primary Care Trusts and GP consortia in other areas of England.

PHDcic and Aetna won the 2010 Health Service Journal (HSJ) Award in the category of Managing Long Term Conditions. According to the Health Service Journal website, the HSJ Awards recognise the innovation and inspiration that is found throughout the health care profession today. The Awards ensure that individuals and teams are both rewarded and celebrated for work that raises the standard of health care in the UK. The best practices are also highlighted for the quality of work being undertaken by all specialties and settings. PHDcic also received a "Highly Commended" 2010 citation for the programme from the NHS Alliance Acorn Award for excellence in the category of Service Redesign and Improvement.