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The Brookside Group Practice created an integrated digital triage and segmentation solution. The solution combines Anima (a digital triage platform) with the Johns Hopkins Adjusted Clinical Groups System population segmentation model (used within the Frimley Integrated Care System and Partners Connected Care population health management platform).
The system applies a RAG (red, amber, green) rating to people’s conditions and needs, identifying those at high risk and enabling effective prioritisation. Combining population segmentation (historical data) with real-time presenting issues ensures efficient triage and streamlined processes.
Patient health teams include both clinical and non-clinical roles and provide team-based care to red, amber and frequent user patients. Patient health teams consist of a partner GP, an associate GP, a physician associate, a social prescriber and a patient services liaison staff member (from the reception team). These collaborative teams aim to provide continuity of care and prioritise people’s wellbeing.
Brookside’s approach demonstrates how digital innovation can improve primary care and health outcomes. The surgery is recognised as an exemplar, and discussions are underway to expand the use of the segmentation and digital triage tool across the ICS.
Key learnings
- Automated stratification combines pre-existing conditions and acute condition stratification to provide a RAG rating, optimising care prioritisation.
- Patient services liaison roles have been introduced to engage with red and amber patients, as well as frequent users, through proactive calling. These roles also complete administrative tasks that previously required a clinician, reducing the burden on clinical staff.
- Strong collaborative team working with monthly patient health team meetings to discuss complex cases. Advice is provided between monthly meetings to ensure ongoing support for the clinical and non-clinical staff involved.
- Use of the tool, alongside clear protocols and training for non-clinical staff, has streamlined and reduced workload for clinicians and staff booking appointments, making best use of roles.
- Clinicians have access to more detailed information on each person, enabling better-informed decision-making. Appointments are for a minimum of 15 minutes, and streamlining requests through the same system allows prioritisation of the most unwell people.
Impact
The Brookside Group Practice reports:
- increased continuity of care – between April and November 2023, people seeing the same patient health team increased from 33% to 66% on average
- improved access – due to online access (over 75% of people chose to use an online form to access care), the average call waiting time decreased from 18 minutes in January 2023 to 4 minutes by December 2023
- improved experience for people and their carers, for example people reported:
“Brookside Practice has excelled at putting patients first and ensuring the patient’s needs are prioritised by administering the right care at the right time in the right place, be it face-to-face or online consultation”.
“I completed the online form at 7:15am and had an appointment at 12pm at the urgent care clinic. Very happy, thank you”.
“Appointment booked via Anima, which I found easy to use, had a response within 15 minutes and a face-to-face appointment within 2 hours. Just what I needed as I was quite worried about my condition”.
Publication reference: PRN01756_ii