University of Edinburgh

N/A

DL_2023_018

Frailty and multimorbidity are terms used to describe people at risk of worsening health, increasing disability and death. These are often older people who have multiple health problems and frequently present to health and social care services at a point of crisis. However, identifying these vulnerable people earlier may allow extra support and assessment to prevent such crises. There are multiple ways of identifying multi-morbid people, but our current record systems for primary care (GP practices), secondary care (hospitals) and social care are not well connected. In this project, we will bring data together data from GP and hospital records to provide a combined view of patients’ health and care information to health and social care partnerships in the Lothian region. These groups are responsible for services that impact the health and wellbeing of the population. No individual level patient data will be shared as part of this project.

The aim of this project is to showcase how HSCPs can gain value from healthcare data that they cannot currently access to better understand frailty and multimorbidity within their populations. This could help to plan services more appropriately for people at-risk of decline. The reports will be written reproducibly, so they can be scaled and transferred for use by different HSCPs with minimal effort. This work will benefit all people who receive care in the Lothian region, as it will facilitate better understanding of their needs to HSCPs who provide many relevant services. Service managers have told us that they have limited access to healthcare data, and that this limits their understanding of frailty and multimorbidity in their care populations. They have expressed an interest in having access to more linked healthcare data to help with planning services. Reports are being designed based on conversations that we have had with HSCPs, where they have highlighted the potential value of combined health and care data. Sharing aggregate information with HSCPs about numbers of patients with common medical conditions, as well as different levels of frailty and multimorbidity will help to highlight opportunities to facilitate preventative care and potentially reduce hospital admissions.

Efficacy & Mechanism Evaluation

06/03/2024

De-Personalised

Release