Improving Care for People with High Levels of Need


(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

The High Resource Individuals team within Living Well in Communities is supporting Health and Social Care Partnerships (HSCPs) through a series of data Deep Dives, to understand how those with the highest level of need interact with services.

Thomas Monaghan, Improvement Advisor, from Healthcare Improvement Scotland’s ihub, and Nathan Devereux, Associate Improvement Advisor, have been contributing to the wider work on High Resource Individuals by exploring ways of improving pathways of care, with support from the Local Intelligence Support Team (LIST) and Information Services Division (ISD).

These Deep Dives help partnerships explore their data on these individuals and identify areas for improvement.

Who are High Resource Individuals?

High Resource Individuals (HRIs) are the small number of people who use a high percentage of hospital and community prescribing resources and inpatient bed days.

HRI 2 PNGIndividual HSCP data

Why focus on High Resource Individuals?

This focus enables an HSCP to understand and learn from the way people with a high level of need interact with services. Through this learning, changes can be made in the future to improve the lives of those with similar needs, and help health and social care services manage capacity and demand.

What is a Deep Dive?

A Deep Dive is a flexible process in which an HSCP immerses itself in the needs of its High Resource Individuals. By using local knowledge and understanding from people who plan and deliver services alongside data on the population group, the Deep Dive:

  • stimulates and structures discussion
  • identifies focus areas for change
  • helps agree actions to support the partnership meet its priorities

Individual HSCP data

The story so far…

The team, in collaboration with Information Services Division and local authority data analysts, are working with a range of HSCPs throughout Scotland, including Glasgow City, Midlothian and Argyll & Bute, to look at the needs of their High Resource Individuals.

The Deep Dives produced are focussed on exploring the demography of the High Resource Individual population, where they live, and how they use the services. In doing so we hope to answer the following questions:

  • Is there a particular age or gender group with a high level of need?
  • Do High Resource Individuals live in a particular part of a local authority area?
  • Is there a pattern in how services and support are accessed?

The Deep Dives also look at other key areas such as substance misuse, falls and end of life, to identify other potential  characteristics in the High Resource Individual population.

Interesting work is developing from these Deep Dives in areas such as improving pathways of care for High Resource Individuals, predicting people at risk of frailty, and models for end of life care.

We will continue to work with the partnerships to map pathways identified through the Deep Dives and support tests of change to improve how people are cared for and supported in the community.


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