Delivering Clinical Health Coaching to Attenborough PCN – Intensity and dynamics of the top 1% and 5% highest users of primary care resources

by Mehdi Juma

HN has been delivering clinical health coaching to the Attenborough PCN in Hertfordshire.

As an extension of this service, our Data Scientists have worked with Dr David Zemmel to identify and focus on the intensity of the top 1% and 5% highest users of primary care resources and uncovered some insightful outcomes.

We’re pleased to share the initial overview of the findings and look forward to building a clinically relevant AI predictive model that will be able to identify these highest users well advance of their sharp increases in demand for care. Download the initial findings.

‘In terms of the analysis, there’s a few things that really stood out for me. I’m certainly surprised at the ratio of females to males in the top 1% most attending patients.’
Dr David Zemmel, Attenborough PCN

‘We were interested in identifying – who were these high intensity users that were causing workload pressures within the practice? Additionally, which patients aren’t in the practice – where is the unmet need?’
Mark England, CEO, HN

‘[Using various data sources] …we will be able to take a much more proactive approach to primary care, making sure there is less unmet need, and focussing on those who need it more.’
Dr Steve Laitner, GP & Public Health Consultant

‘Our patients from primary care are more focused on the day-to-day realities of living with a chronic disease. We found that these patients see a higher level of anxiety and depression than the patients we see in secondary care.’
Creenagh Williamson, Chief Nursing Officer & COO, HN

Watch the video about our work with Attenborough PCN.

Find out more about our services for Primary Care.