The GPs identified 2500 patients who did not need immediate care from community matrons or GPs but who were at risk of hospital admission because of broader health or social issues associated with age and frailty. Only 300 of them would have been captured by the unplanned admissions DES.

In just nine months, A&E attendances and admissions fell by 54% and requests for home visits from the GP dropped by 81%. The practice had received around eight discharge letters every day - it now receives just three or four a week.

South Tyneside NHS Foundation Trust seconded an older persons' specialist nurse (a post now substantive in the practice) to co-ordinate and implement care plans. As well as GPs, the team also includes nurses, a primary care navigator, a practice-based occupational therapist and community matrons. Using EMIS Web, all of the healthcare professionals in the team can write and update care plans.

Practice Manager Sheinaz Stansfield explained: "It's all about teamwork. For example, our primary care navigator and healthcare assistants will call at-risk patients and identify health and social factors that could affect their health; an individual could be feeling isolated and not eating properly - a situation which could make them more susceptible to infection.

"Knowing that, the broader team are able to suggest action - including the best people to take action - to prevent the situation from escalating. It might be that the district nurse could time a visit to check what's on the menu. It's about moving from reactive treatment to proactive and preventative care.

"Making sure all those involved in an individual's treatment are aware of progress in real time, through a shared record is essential.

"Previously this was a challenging task. Community services teams, for example, were on a different IT system entirely which added extra administrative layers and delays to updating patient records. Now we all sit down and have regular planning sessions. It is patient-centric care made a reality."

She added: "The success of the scheme has also enabled us to make business cases - backed by data - for additional support to our CCG. For example we were able to show that an in-practice occupational therapist would actually save time, resources and money by working with patients, maintaining independence and reducing hospital admissions or care home admissions."

Related news articles:

• EMIS' Profile

About EMIS Health
EMIS Health is part of EMIS Group plc - the UK leader in connected healthcare software and services.

EMIS Health provides software and services to clinicians working across every major UK healthcare setting, including:

• Primary Care - market leader with 54% share of the UK GP market; its systems hold 40 million cradle to grave patient records;
• Community Children's and Mental Health Care - 9% and growing UK market share;
• Secondary Care - 81% of NHS Acute Trusts use an EMIS Health system; its software holds 30 million patient records in A&E alone;
• Community Pharmacy - the single most used integrated community pharmacy and retail system (36% UK market share);
• Specialist Care - EMIS Health is the leading provider of software and services to support diabetic eye screening (82% English market share) and other ophthalmology and specialist services.

EMIS Health is an innovator in secure data-sharing to join up healthcare. It was the first in the UK to enable community pharmacists to access information from the GP patient record - supporting safer dispensing - and the first to integrate personal health data captured on wearable consumer devices with the GP patient record.