1. An overview of Parr in
practice in Northern
Ireland.
Marina Lupari
Head of nursing- research &
development, NHSCT/PhD student, UU

2. Key Statistics for Northern Ireland
 1.8 people living in N. Ireland
 160k emergency admissions to hospital each
year.
 Over 700k attendances at A&E Depts.
 Our Ambulance service provides over 350k
journeys, of which 88k are emergencies.
 5 integrated Health & Social Care Trusts.

4. About the NHSCT
 The Northern Health and Social Care Trust provides
a broad range of health and social care services.
 The Northern Health and Social Care Trust became
operational on 1 April 2007, combing 3 legacy trusts.
 It is geographically the largest trust in Northern
Ireland and operates from approximately 150
locations, serving a population of 443k people.
 The Trust employs approximately 14,000 staff. We
have an annual budget of £550 million.
 We provide a range of services from nine hospitals
and a large number of community based settings
including people's own homes.

5. Drivers for Change - 2004
 The Health Economy had recognized a need for
tighter financial efficiency and cost effectiveness in service
delivery.
 better approaches to the management of chronic disease.
 These multiple challenges included:
 the under-coordination of health services, limited incentives and
training for health care professionals.
 poor diagnostic methods, limited disease management
protocols, lack of patient involvement in managing disease.
 stove-piped funding mechanisms.
 These realities underpinned:
 recent efforts to change existing structures and practices in
order to increase service efficiency in chronic disease
management
 and improve health outcomes for people living with chronic
illness.

7. Care pathways links between primary, secondary and community care services in
chronic disease management
Primary Care Secondary Care
Patient with suspected Chronic Patients with known Chronic condition –
disease exacerbation of condition
Hospitalisation
Appropriate investigations to
confirm diagnosis
Community Based
Specialist Nurse PARR Assessment
GP referral onwards for support
Continuing Care Nurse Case Finder
(CCN) visits pt at home Case Management Co-ordinator
Patient assessment, review, treatment, education, referral to other professionals services &
support programmes including domiciliary services
Primary Community rehab Chronic Conditions ACAHT- Multi Patient Asst.
Care inc cardiac/ Management acute skills support Technology
Nursing pulmonary rehab programme needs network Group
Team

8. Care pathways links between primary, secondary and community care services in
chronic disease management
Primary Care Secondary Care
Patient with suspected Chronic Patients with known Chronic condition –
disease exacerbation of condition
Hospitalisation
Appropriate investigations to
confirm diagnosis
Community Based
Specialist Nurse PARR Assessment
GP referral onwards for support
Continuing Care Nurse Case Finder
(CCN) visits pt at home Case Management Co-ordinator
Patient assessment, review, treatment, education, referral to other professionals services &
support programmes including domiciliary services
Primary Community rehab Chronic Conditions ACAHT- Multi Patient Asst.
Care inc cardiac/ Management acute skills support Technology
Nursing pulmonary rehab programme needs network Group
Team

9. Overview of the PARR Tool and
Data Preparation Process
Patient admitted/discharged
Activity recorded on Trust PAS
PARR DATABASE
Activity downloaded into PARR Via
Business Objects, Trust Designed MS
Access Database
Sifting & criteria Risk Level Identified
applied
OTHER
PATIENT
DATA APPLIED
CASE FINDING DATABASE CCN Nurse assesses, accepts
THE ‘CASELOAD MANAGEMENT’ PROCESS

11. Initial review of CICM service
Within 1
year
PRIOR
1-2 years to Within 1 year
PRIOR to Referra AFTER
Referral l to Referral
to CCN CCN to CCN
Activity Type service service service
Admissions 110 215 143
Spell Beddays 1466 2307 1903
Avg LoSpell 13.3 10.7 13.3
% of Individuals who had Adms in year
(%/167) 35.3% 68.9% 38.3%
Avg No. of Relevant Adms per individual
(n=167) 0.7 1.3 0.9
Actual No. of Individuals who had relevant
Adms in the year 59 115 64

12. Admissions to UHT by Diagnostic Group
- for those Admissions in both Year BEFORE & AFTER Referral to CCN
Count of Date of Admission Only
35
30
25
20 Post CCN Service
15
10
5
0
Jul
Jul
Jul
Aug
Aug
Apr
Apr
Sep
Feb
Sep
Feb
Jun
Jan
Jun
Jun
Jan
Jun
Dec
Dec
May
May
May
May
Nov
Nov
Mar
Mar
Oct
Oct
2005 2006 2006 2007
2. within 1 year PRIOR to Referral to CCN service 3. within 1 year AFTER Referral to CCN service
Condition
Diabetes Heart Other Resp
Time Banding Years Date of Admission Only

13. Drivers for Change - 2007
 Proposal to Centralise the PARR Analysis to allow for the
identification of admissions/activity across different
providers to be integrated.
 Trusts moving to “Real Time” recording of Clinical
Diagnoses and thereby aiding the identification of
prospective “Caseload Management” patients in real time.
 Regional Unique Identifier now available i.e. HCN to track
individuals across services.
 Need to tie in other data sources, i.e. Primary Care activity
such as Attendances at surgery, Out of Hours service
usage, Medications etc. to improve complexity of PARR
Tool (subject to evidence/research).
 Organise for N.I. Deprivation Measures to be added to
PARR Tool.
 Need to understand full capability of PARR and it’s
application to service provision.

14. Summarisation of key components of
study design & methodology
April 06… June 2008- November 2009 approx
Intervention Group Comparison Group
Locality A (n=295) Locality B (n=295)
Case Usual Care
Management CM Care
Introduced
Data Gathering
Data Gathering Patient specific
Locality A
Patient specific FIM
FIM HR-QOL
HR-QOL Economic Proforma
Economic Proforma Carers Strain Index
Carers Strain Index - Carers Focus group
- Carers Focus group

15. Research Objectives and link to
PARR
 Aim- to establish if the introduction of a case management
approach for chronic conditions is effective and/ or cost effective
 Does PARR predict patients accurately at risk of
rehospitalisation and how can we move towards prediction of
avoidable rehospitalisations?
 What is the relationship between PARR, reduction in
rehospitalisations and the intervention?
 Is there any relationship between PARR and the specific chronic
condition, and/or presence of co-morbidities ?

16. “PARR” identified referrals to CICM
Result of Assessment No. %
CCN caseload 1122 33.5%
CCN Discharge 319 9.5%
Mortality 670 20.0%
Renal Failure 27 0.8%
Inappropriate referral CCN 826 24.7%
Other handover 103 3.1%
Palliative care 82 2.4%
PCNT handover 46 1.4%
Service declined 154 4.6%
3349
Position @ Jun09

17. Distribution Chart showing PARR Scores across Research Groups
Count of ID
250
216
199
200
150
100
56
44
50
23
14 10 9 5 4 1 4 1 2 2
0
20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99
Research Group
Control Group Intervention Group
PARR

18. Distribution Chart of Major Chronic Conditions by Research Group
350
295 295
300
250
200 193
186
158
145
150
113 113
100
61
46
50
0
No. in Research Group Asthma COPD Diabetes Heart Failure
Control Group Intervention Group

19. 0
10
20
30
40
50
60
70
80
Asthma
Asthma / Diabetes Count of ID
Asthma / Diabetes /Heart
Failure
Asthma/ COPD
Asthma/ COPD/ Diabetes
Asthma/ COPD/ Diabetes/
Heart Failure
Asthma/ COPD/ Heart
Failure
Control Group
Research Group
Asthma/ Heart Failure
Chronic Conditions
COPD
Drop Page Fields Here
Intervention Group
COPD/ Diabetes
COPD/ Diabetes/ Heart
Failure
COPD/ Heart Failure
Diabetes
Distribution Chart showing the Multiple Co-Morbidities for Research Groups
Diabetes/ Heart Failure
Heart Failure

20. PARR
Chronic Conditions Research Group 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-99 Total
Asthma Control Group 4 2 2 1 9
Intervention Group 7 2 9
Asthma / Diabetes Control Group 6 1 1 8
Intervention Group 15 2 17
Asthma / Diabetes /Heart Failure Control Group 3 1 4
Intervention Group 1 2 3
Asthma/ COPD Control Group 1 1 1 3
Intervention Group 2 1 1 4
Asthma/ COPD/ Diabetes Control Group 2 1 1 4
Intervention Group 4 4 8
Asthma/ COPD/ Diabetes/ Heart Failure Intervention Group 2 2
Asthma/ COPD/ Heart Failure Control Group 2 2
Intervention Group 4 1 5
Asthma/ Heart Failure Control Group 10 4 2 16
Intervention Group 12 1 13
COPD Control Group 29 14 3 4 1 51
Intervention Group 47 3 1 2 2 1 1 57
COPD/ Diabetes Control Group 14 4 1 19
Intervention Group 21 4 1 2 28
COPD/ Diabetes/ Heart Failure Control Group 12 5 3 1 1 22
Intervention Group 14 2 1 1 18
COPD/ Heart Failure Control Group 34 6 3 1 44
Intervention Group 50 10 6 2 1 1 1 71
Diabetes Control Group 9 1 3 1 1 15
Intervention Group 7 5 1 1 14
Diabetes/ Heart Failure Control Group 34 5 1 1 41
Intervention Group 15 5 2 1 23
Heart Failure Control Group 39 13 2 2 1 57
Intervention Group 15 3 3 2 23
Grand Total 415 100 37 19 9 5 3 2 590

21. Distribution Chart : Showing "relevant" rehospitalisations
Sum of SumOfAdmissions
100
89
90
80 76
70 63 63
60 51 52
47
50 42
40
30
20
10
0
T0 T3 T6 T9
Yes
Research Group
Control Group Intervention Group
Included in Study T Band

22. Distribution chart: Beddays by Relevant Conditions across Research
Groups
Sum of SumOfLength of Spell1
800
678 699
673
700 632 649
600 560
500
384 367
400
300
200
100
0
T0 T3 T6 T9
Yes
Research Group
Control Group Intervention Group
Included in Study T Band

23. Distribution Chart: Relevant Adms by PARR Score
160 150
140 132
120
100
80
60
48
37
40
18 20 20
16 15
20 11
8 7
1
0
20-29 30-39 40-49 50-59 60-69 70-79 80-89
Yes
Control Group Intervention Group

24. What have we learnt so far ?
 We know PARR can predict people at risk of
all rehospitalisations for about 75 % of people
 We know PARR and our intervention can
save rehospitalisations / beddays
 We know we need to look at how better to
predict those people at risk of avoidable
rehospitalisations
 We need to look at the impact of social
deprivation for NI

25. So where to now?
 Continue with data analysis
 Investigate the relationship of PARR and
avoidable re hospitalisations more fully
 DHSSPS have agreed to run PARR across NI
 Look at what everyone else is doing and see
how we can improve