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Managing risk in reducing admissions for people with long term conditions in Yorkshire

In Kirklees the introduction of emergency care plans for people with long term conditions has led to a reduction in unnecessary hospital admissions An emergency care plan is placed in the patient’s home and provides information for both patient and professionals to promote self care and enable safe clinical decisions to manage patient care in the right place at the right time, avoiding unnecessary hospital admissions. This model of care is supported by a multi disciplinary team/agency approach to the management of people with long term conditions. This includes the use of risk profiling to identify frequent ambulance callers and A&E attendees, MDT meetings to decide on appropriate care for individuals and active case management or sign posting on to other services where appropriate. This model has been developed and integrated across the country and across several ambulance services. Recently Yorkshire Ambulance Service and locala community partnerships were highly commended for this work and with older people in the nursing times awards 2012. They were finalist in 2010 and 2011.

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