Overview
This Standard Operating Procedure (SOP) provides detail on how BrisDoc records, identifies, manages, and monitors High Intensity Users (HIUs) for BrisDoc Integrated Urgent Care (IUC).
Practice Plus Group (PPG) have an independent HIU process which is out of scope for this SOP. However, co-ordination of HIUs when there are HIUs which fall across both organisations is documented in this SOP.
The objective of the HIU SOP is to ensure a holistic assessment of HIUs, addressing any unmet needs within primary / urgent care through arranging multi-disciplinary team meetings (MDTs), creating care plans, regular and timely dialogue with stakeholders and active monitoring.
Sometimes, patients are identified as HIU of systemwide services, these patients will, if they meet the threshold, be discussed via the Integrated Access Partnership (IAP) HIU Group. There is a separate process for engagement across IAP partners.
Definition of HIU
High Intensity User (HIU) is a nationally recognised term for individuals with unmet needs. These are usually non-medical factors, including age, housing instability, social isolation, loneliness, deprivation as well as poor physical and mental health. HIU management is designed to address health inequalities, free up front-line resources and enable parity and equality across the system while reducing costs. It requires system-wide engagement, of primary, secondary, social care, urgent care and emergency services with the goal of all providers working together, collaboratively, to maximise the best use of available resources.
The definition of HIU for BrisDoc Integrated Urgent Care (IUC) is defined as an adult who makes 5 or more calls that are transferred by NHS111 to the IUC Clinical Assessment Service (CAS) within a calendar month or 12 or more calls within a continuous 3-month period.
Roles and Responsibilities
Business Intelligence Analyst
The Digital Team are responsible for running the Adastra monthly ‘Frequent Callers by Surgery’ report (excluding palliative care/deaths). This is done at the start of the month and the data is for the previous calendar month. The data is copied and pasted into the HIU Audit Excel workbook. Information from the report includes all relevant assessment data to ensure there is a full history to enable a comprehensive audit.
Lead Clinical Practitioner
The Lead Clinical Practitioner (LCP) for HIUs is responsible for assessing and managing the HIU audit spreadsheet monthly. The spreadsheet is accessed via S:GOVERNANCE TEAM/CONFIDENTIAL-DAC/HIGH INTENSITY USERS/HIU Audit and requires a password for access which can be obtained from the Business Intelligence Analyst, Lead GP for HIUs or the LCP for HIUs. The assessment of each patient entails review of EMIS, patient records and Adastra records to ascertain whether the patient should be discussed at the Monthly High Intensity User Meetings. The LCP for HIUs will prepare a list of patients for discussion with the Lead GP for HIUs. The LCP for HIUs is also responsible for chairing the Monthly HIU Meeting, updating special notes, corresponding with agencies, and attending Multi-disciplinary Meetings (MDTs).
Lead GP for HIU
The Lead GP for HIUs will meet with the LCP for HIUs before the HIU Meeting. The Lead GP for HIUs will discuss appropriate management plans with the LCP for HIUs. The Lead GP for HIUs is responsible for updating special notes within Adastra which consists of a care plan, corresponding with stake holders and attending MDTs. The Lead GP for HIUs will also chair the Monthly HIU Meeting in the absence of the LCP for HIU.
Quality Manager
The Quality Manager attends Monthly HIU Meetings, arranges and attends MDTs. The main role of the Quality Manager is to ensure that there is a robust governance process for managing HIU patients. The Quality Manager may correspond with other stakeholders as required.
Standard Operating Procedure
Monthly Audit
The HIU Audit spreadsheet includes patient demographic details, and the following HIU information:
- Total calls per patient
- 12-month activity graph
- Month of first and latest calls
- Profile of call activity for past 6 months
- Number of calls in past 2 months
- Mental Health Team involvement
The Monthly Audit Review
The LCP for HIUs reviews the HIU Audit spreadsheet, Adastra records and EMIS patient records monthly. The following fields are updated for each HIU:
- Patients are assigned for review or watchful waiting dependent on circumstances surrounding the assessment of the contacts. Cases marked for review are flagged to the Lead GP for HIUs, discussed, and an action plan put in place.
- Patients are assigned Active or Inactive under Status column (Inactive patients are those with no calls in past 3 months).
- Patients have the date patients have been reviewed under Last Review column updated.
- Clinical judgement is used to assess a risk category of low, medium or high risk identified for each HIU using a holistic assessment.
- Patients with a mental health diagnosis are identified with Yes or No under Mental Health.
- Patients due for MDT are marked Yes or No under MDT
Pre-HIU Meeting
The LCP and Lead GP for HIUs meet to discuss cases for review and caseload for the HIU Meeting. In some instances, special notes will be added to patient Adastra records in terms of a Care Plan or patients will be monitored without immediate need for HIU Meeting discussion. Patients identified via learning events or highlighted as potential HIU are also reviewed at this meeting. The HIU spreadsheet is updated following this meeting.
The monthly HIU Meetings requires representation by SevernSide IUC and is attended by the LCP for HIUs, Lead GP for HIUs, Quality Manager, and HIU Leads for NHS 111 from PPG. The purpose of these meetings is to ascertain unmet patient needs that could be addressed with appropriate HIU intervention. Patients will be part of an agreed agenda and the following possible outcomes will be determined for each patient discussed:
- Create shared care plans that are added to special notes within patient’s Adastra
- Arrange an MDT with GP of patient and other stakeholders
- Informal contact with GP of patient through email
- Other bespoke interventions – Learning Disability Care Plan
- Monitoring interventions in place for HIU
HIU Meeting minutes are recorded, distributed and added to the S:/ drive by the Lead LCP for HIUs or a member of the Governance Team.
The objective of the HIU Meeting is to enable collaborative working in the holistic management of HIUs between primary GP Practices and SevernSide IUCS ensuring the engagement of other stakeholders that may be deemed necessary in HIU management.
IAP Meeting
The Integrated Access Partnership (IAP) HIU group holds representation from South Western Ambulance Service (SWAFST), Mental Health (AWP) and SevernSide IUCS and is a collaborative and innovative platform to address HIUs that are systemwide service users.
HIU from SevernSide IUCS, may meet the criteria for discussion at this forum and the Lead LCP for HIUs and Lead GP for HIUs will refer to this service as required. The referral process is generally via IAP data collection, however in exceptional circumstances a HIU can be raised with the group for discussion. A data sharing agreement is in place across all the relevant services.
Special Notes
Special notes can be viewed by NHS111 colleagues, and BrisDoc operational and clinical co-owners working for SevernSide on Adastra. Special notes are added for patients for whom additional information will help clinicians to better meet their needs. Special notes are also added to alert clinicians where a patient may have a history of verbal or physical aggression or drug seeking behaviours. Access needs to be granted on Adastra to update special patient notes. The LGP and LCP for HIUs have the necessary access to manage these notes.
Creating / Amending/ Deleting Special Notes
Special notes are added in Adastra by going to Patient Administration and choosing ‘note edit’. The patient can then be searched for by name. It is important to confirm the correct date of birth and address for the patent. New notes can be written by going to the ‘new note’ button, in the bottom left of the screen. Once the note has been added, click ‘update’ to save the note. The new note will not be visible in the special patient notes for cases prior to the date the note was added.
A note can be removed from the clinician’s view of special notes but is saved within the special notes function. This can be done by selecting the ‘obsolete’ function. It is advised that patient’s only have one special note visible at a time. The HIU group are working to summarise multiple special notes for the highest HIUs.
If a note needs updating, it should not be amended, but copied, then tick the obsolete button and click update. A new note can then be written as above, the obsoleted note can be pasted and amended if needed.
Formatting special notes
Special notes are written in the following format:
***Special Patient Note ***
Situation
Background
Assessment
Recommendation
Date, Name of Clinician, Role
How to request a change/ review Special Notes
Clinical and Operational colleagues are encouraged to submit learning events if they feel a special note needs further detail adding to assist clinical colleagues for future calls or a patient requires special note adding.
Reporting HIU Indicators
This is an area currently being reviewed. A quarterly report of HIU activity will be created for the Quality and Performance Report for Commissioners. A smaller update is planned for monthly for Quality Board. There are also plans for an annual Clinical Audit to ascertain the effectiveness of HIU management within the service.
Version control
| Date | Version | Author | Changes |
| 23 / 09 /13 | 2 | C-L N | Updated |
| 13/1/14 | 2.1 | BD | Change of format |
| 29/01/14 | 2.2 | LG | Updated |
| 20.4.15 | 2.3 | CLN | Updated titles and inclusion of exclusions |
| 7.01.2018 | 2.4 | LG | Updated |
| 25/03/19 | 2.5 | BD | Updated |
| 30/11/2023 | 2.6 | CD | Rewritten and renamed from Frequent Caller SOP |
| 8/12/23 | 2.7 | LW | Minor changes and special note section added |
| 21/12/2023 | 2.8 | CD | Final minor amendments. |
| 7/2/24 | 2.9 | LW | Minor amendments |