engaged with Suvera outreach for proactive frailty review
South Central has a list size of 50,000 patients and is part of North West London ICB.
The frailty service built on our previously successful partnership with the PCN for diabetes virtual group consultations, which had surpassed network enhanced services targets. The PCN set a target for frailty care plans to be completed for 2% of the patient population.
Utilising SystmOne data, Suvera created a register of patients who were high intensity users, and/or are vulnerable or frail. The team identified who would benefit from a care plan or require multi-agency support. Suvera technology automated patient outreach, prescheduling appointments with translation services also provided if required.
It was a pleasure to work with Suvera clinicians who delivered care plans for our patients with severe frailty. The reviews were very comprehensive and enabled health and social needs to be identified and action plans implemented to improve patient wellbeing. Suvera were well received by our patients. We would not hesitate to work with them again.
Suvera’s specialist clinical pharmacists delivered holistic frailty reviews and co-developed care plans with patients and carers. A dementia review was also performed. The goal of each care plan was to outline optimal strategies, review medications and reduce risk of hospital admission.
Suvera achieved PCN target, completing 1000 care plans across five sites. Furthermore, the pre-scheduling system saw patient engagement rates of 74%, providing an easy means for individuals to reschedule consultations as needed.
It was a pleasure working with the patients and healthcare professionals of South Central Ealing PCN. Patients benefited from the service and provided positive feedback. Thank you to the PCN who were very supportive in achieving the goals set for the service.
- Farahnaaz Joomun, Clinical Pharmacist, Suvera
With sub-optimal management of severe frailty estimated to cost the system up to £2100 annually per person, 1000 patients on optimal care plans could potentially deliver £2.1m in savings to the NHS every year.*
