An innovative project, which helps nurses, GPs and social care staff identify frail, elderly people with long term conditions so that they can be treated and cared for at home has won a prestigious national award.

Andy Boocock, Information Analyst with Luton Adult Community Health Services designed an easy to use interactive digital data dashboard for partners across health and social care as part of a wider programme of work to meet the challenges posed by the town’s growing elderly population. The tool allows elderly people to be identified, whether they are living in their own homes or care homes, so that health care plans can be put in place to avoid unnecessary hospital admissions.

The Population Health Management Tool project won the Improving Care for Older People Award category of the HSJ Patient Safety Awards recognising its outstanding contribution to healthcare.

The Luton Adult Community Health Services team – part of Cambridgeshire Community Services NHS Trust – were recognised for “their ambition, visionary spirit and the demonstrable positive impact that their project has had on patient and staff experiences within the health and social care sector.”

Andy said: “This tool brings together the data from hospital and accident and emergency admissions of frail, elderly people over the age of 65 and presents it in such a way that it can be easily understood by those working in the health and social care sector. It is documented in one place so that everyone can use it and we can prioritise the health needs of elderly people.”

The team works with partners in Luton and Dunstable Hospital, primary care, social care, ambulance service, mental health and voluntary sector and this tool helps them to provide joined-up care for the people they serve.

GP Haydn Williams said: “This is an incredibly powerful tool. It helps us to organise our frailty clinics and to address the needs of our elderly patients before they get sick so that we can anticipate their health needs. 

“During Covid, it has allowed GPs to very quickly identify those patients in care homes so that we can put care plans in place to help them should they get sick.”

Pete Reeve, Service Director, Luton Adult Community Health Services added: “We are absolutely delighted to have won this award. Although this award goes to CCS this is really a testament to the collaborative approach in the Luton system; colleagues from our Primary Care Networks have been instrumental to making this work. 

“We know that elderly people who need medical help recover far quicker at home surrounded by their families and we work with our partners to make that possible. This tool helps us to identify those vulnerable elderly people who need our help and put in place care plans to prevent them having to go into hospital unnecessarily.”

Luton CCG has been very supportive with this project, it’s forward thinking and innovative ethos have really driven forward innovation in Luton.

Amanda Flower, Associate Director, BLMK CCGs said: “The relationships in Luton that allow collaborative pieces of work such as this to flourish have taken time to develop and are so important.  It’s great to be a part of it – we can really build on this.”

The HSJ Awards judging panel said: “This is an excellent example of improving care for older people. Patients too often fall through the gaps and there often isn’t the technology to identify these patients. 

“The population health tool is a great example of being able to identify patients early and put steps in place to prevent a deterioration of their condition. This is a truly responsive collaborative partnership approach to supporting older people with clear benefits applied during Covid-19.”