This is based on a concept developed in North Devon with the intention of identifying patients at high risk of admission to hospital over the next 12 months. 

Patients are identified by using a computerised prediction model. This looks at a number of factors including the number of A&E attendances and hospital emergency admissions over the last two years as well as the presence of various chronic diseases. All information is kept confidential within our multidisciplinary team.

Those patients are then discussed by a multidisciplinary team once a month.

Evidence suggests that this approach can lead to a reduction in hospital admissions with improvement in health of the patients involved. The higher risk patients will have regular contact with the team – often our Community Matron, Tina Green.