AHSN Impact Report 2021 - Page 24

Structured health coaching to reduce unplanned hospital admissions
With our partners at Humber , Coast and Vale Health and Care Partnership , we used funding from the Joined Up Care Programme to build upon the successful introduction of HN ’ s Clinical Coaching CARE service in York . This is a six-month , high intensity clinical coaching and navigation intervention programme that uses Artificial Intelligence ( AI ) and personalised care to identify patients with long-term conditions , who are at high risk of deteriorating and needing unplanned acute and emergency care .
HN ’ s predictive algorithm is supported by well-tested and robust information governance , complying fully with GDPR . Patients are supported by a clinical coach – a telephone-based , nurse-led service – that aims to support patients ’ needs and improve care coordination with other services . The role of a clinical coach is to build relationships , understand context and work alongside other healthcare professionals and services to create a Personalised Care Plan .
Our project will benefit 1,000 patients in the Humber Coast and Vale region by helping these individuals to improve selfmanagement of their conditions , reducing unnecessary hospital admissions by 30-40 % and visits to Emergency departments by 20 % -30 % within a year .
We made a successful bid for funds to spread the HN model based within secondary care from York into populations in Scarborough and Ryedale and Harrogate and District . We also worked with Vale of York Clinical Commissioning Group ( CCG ) to further develop the HN model , this time rooting it within primary care – York Primary Care Network . We are also continuing to support HN with a patient and public engagement programme .

1000 patients will be

supported to improve the self-management of their conditions
Hospital admissions will be reduced by up to
Visits to Emergency Departments will be reduced by up to

30 % 40 %

18 Transforming Lives Through Innovation