AI tech to identify vulnerable NHS patients in bid to prevent falls and hospital visits

AI technology is set to browse medical records in a bid to identify patients who may need support – before they actually need it.

Artificial intelligence tools are being introduced to GP practices across the south west in a bid to help them offer earlier support to people at risk of hospital admission.

The Brave AI system, which helps staff identify vulnerable patients who may otherwise go under the radar, will be rolled out to 30 areas over the next few months.

This follows a successful pilot in care homes in Somerset which reduced resident falls by 35%, attendances to Emergency Departments by 60%, and ambulance call-outs by 8.7%.

The system uses an algorithm to look for patterns in registered patients’ records, and assesses an individual’s risk of unplanned hospital admission in the next year.

Integrated neighbourhood teams of nurses, pharmacists, therapists, health coaches, social prescribers and doctors then use the information to reach out to those flagged by the system.

They can then offer to put in place personalised support, such as setting up remote health monitors, offering apps to self-report wellbeing, or linking up with voluntary groups or classes to avoid loneliness.

The scheme identifies people who could otherwise have gone unnoticed, such as those without a major diagnosed condition or those who rarely contact their GP.

NHS England South West medical director, Dr Kheelna Bavalia, said: “No one likes going to hospital unexpectedly so it’s much better for everyone if we can make good plans in advance and respond quickly to changes, before emergencies happen.

“Working together as a ‘team of teams’ of health and care professionals is key to helping us support people to stay well at home for longer and ensuring our system is as efficient and effective as possible, particularly in winter when demand is high.

“It will allow our healthcare professionals to start conversations early so that people can be directly involved in discussions about their care and help healthcare professionals understand what’s important to them.”

NHS national director for transformation, Dr Vin Diwakar, said: “NHS teams around the country are constantly identifying new, innovative digital solutions to help improve patient care, and this expansion of the Brave AI system right across the South West is a significant step forward in providing vital support for those most at risk of a hospital admission.

“These measures not only keep some of the most vulnerable patients out of hospital but encourage conversations with patients who might not otherwise contact their GP, spotting health conditions that might otherwise go unnoticed and boosting our ability to intervene early when conditions are easier to treat.”

The new contract, awarded to Bering Limited through NHS England’s South West Digital Neighbourhoods programme, aims to make the South West the most digitally enabled region in England.

The system will now be expanded to 30 further groups of GP practices in Gloucestershire, Wiltshire, Somerset, North Somerset, Dorset, Devon and Cornwall.

Following evaluation the aim is to then roll-out the scheme across all areas of the region.

Dr Ignat Drozdov, managing director of Bering Limited, which will be supplying the digital tool, added: “We are delighted to be supporting healthcare professionals in the South West with our innovative technology.

“By helping health and care providers to identify the people at greatest risk of going to hospital, the focus can shift to prevention rather than cure, supporting proactive conversations, and ensuring that care and treatment can be planned in advance.”

Primary Care Networks (PCNs) are groups of GP practices working with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas.

As part of its Brave AI pilot in primary care, NHS Somerset worked with the North Sedgemoor Primary Care Network (PCN) to put together a clinical primary care team with differing skills sets including pharmacists, GP’s, occupational therapists and nurses.

They looked at data from more than 500 care home residents across 35 care homes and tracked their health and care across 18 months.

The team found by using the Brave AI tool and working together as an integrated team they were able to provide proactive care to patients in this cohort which has led to:

1. A 60% reduction in attendance at hospital A&E departments
2. A 35% reduction in falls (which often lead to ambulance call outs and hospitalisation)
3. An 8.7% reduction in ambulance call outs.

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