SPARRA Made Easy

SPARRA Made Easy

Guidance developed by Long Term Conditions programme teams from Lanarkshire, Ayrshire and Arran and Greater Glasgow and Clyde in collaboration with ISD Scotland

Understanding SPARRA

The purpose of this guidance is to provide health and social care practitioners with an understanding of SPARRA data and its role in the delivery of Proactive, Planned and Co-ordinated care for people with complex or frequently changing care needs.

We have listed some Frequently Asked Questions, suggestions and solutions.

What does SPARRA mean?

SPARRA stands for…

• Scottish
• Patients
• At
• Risk of
• Readmission and
• Admission

What is SPARRA data?

SPARRA data is a way of identifying those people at greatest risk of emergency admission to hospital over the next year. The SPARRA tool was developed by Information Services Division ( ISD). It identifies people who have entered a cycle of repeat admissions to hospital in the previous 3 years and predicts their risk of future hospitalisation. From January 2009, SPARRA data has been enhanced to provide risk scores for people of all ages.

Why would I want this information?

The information on the SPARRA lists supports your local team to provide the proactive, planned and co-ordinated care required for people with complex or frequently changing needs. Instead of reactive or crisis care, people and their carers will receive an improved service through a more robust assessment and care planning approach. Delivering continuous, supportive care with a single point of co-ordination improves the experience for the person and their carer, supports care at home and may prevent avoidable hospital admissions.

Any member of your team ( e.g.GP, District Nurse, Practice Nurse, Community Psychiatric Nurse, Allied Health Professional, Social Worker or Care Manager) may already be providing care to people on the SPARRA list. Using SPARRA data regularly and systematically will prompt opportunities for discussions at multi-disciplinary, multiagency team meetings within Practices or other settings. Practitioners can reassess the person centred care plan, address any gaps in a collaborative way and make more effective use of the local team and services.

How often will I get a SPARRA list?

SPARRA lists are currently distributed to General Practice teams four times a year. Make sure you know who will distribute your list and when to expect it. SPARRA data is confidential and should be handled in line with local data sharing and information governance protocols. Each list will include names of people already identified from previous SPARRA data plus a new cohort.

What format will the list be available in?

SPARRA data from ISD is received in GP Practice specific format. If your SPARRA list is provided in an Excel spreadsheet it may be arranged by GP Practice code number. The list may need to be 'cleaned up' by cross matching with the Practice's clinical system to exclude people who may have died or moved away. SPARRA data logs up to 16 conditions if recorded on the hospital record. You can filter the output to select people with a particular condition or combination of conditions. These can be colour coded for easy reading and to quickly identify groups of particular interest, e.g. colour all patients with COPD in yellow, show new names in green and people with increased risk scores in red.

How can I use the SPARRA list to identify people with a high risk of being admitted to hospital?

The SPARRA list will alert you and the multi-disciplinary, multi-agency team to a group of people who are at risk of being admitted to hospital in the next year. The threshold for 'high' risk can be set at any point - this threshold will vary for local NHS Board areas. Most teams consider 'high' risk as those people with a risk score of 50% or more.

You and other members of your local team will already know many people on the SPARRA lists. Through discussions at your team meetings, at Practice or locality level, you can reach decisions about the most appropriate lead practitioner to follow up the assessment and care planning for each person. Appendix 3 provides examples of PDSAs showing how SPARRA data was used by a district nursing team to identify patients at risk of hospital admission.

Will all patients identified from SPARRA require Care Management?

Not all of the people on the SPARRA list will require to be care managed. Some people, for example those who need less intensive interventions and those in low to medium SPARRA risk groups, will benefit more from other targeted approaches from a range of practitioners with the skills to support self managed care. These targeted approaches include provision of information, education, advice and support from the practice nurse, community rehabilitation team and from local community and voluntary sector partners.

A decision about the most appropriate intervention and arrangements for review will be made following multi-disciplinary discussion and assessment. The decision regarding care management and the appropriate level of support required should be made in partnership with the patient and carer, shared at integrated team meetings at Practice and locality level, and communicated to all other partners involved in the person's care.

The 65+ SPARRA list identified 14 patients in my practice with over 50% risk of hospital admission. After 'cleaning' the data I found that four had died, three were in long term care and two were appropriately linked to the practice nurse. This meant that my team had only to review and assess three patients for care management before the next SPARRA download in 12 weeks time.
A District Nurse from Lanarkshire.

How else can I identify people needing to be care managed?

SPARRA is only one way of identifying people at high risk of admissions. You can identify people who will benefit from care management by sharing local intelligence at Practice and locality team meetings and by using other community risk prediction tools. Weekly hospital Emergency Admission data gives real time information. Social Work Services hold useful data on dependency in Indicator of Relative Need ( IoRN) Scores and in Single Shared Assessments ( SSA). Practice registers hold disease specific and prescribing information.

How should I share SPARRA information?

It is important that each locality has a robust integrated system that includes opportunities for you and your team to discuss people on the SPARRA lists with other partners providing care and services. Where care management is considered appropriate for an individual, the team should agree the 'best placed' lead practitioner or care manager for that person from Community Nurses, Social Work, Allied Health Professional or Mental Health Team. The lead practitioner will plan, co-ordinate, monitor and review care for the person and their carer. This approach reduces duplication of work and confusion for both the person and their carer. All providers, including Out of Hours services, should be alerted to the risk of hospital admission and know how to contact the appropriate care manager. A sample notification form is attached at Appendix 2.

Reporting SPARRA data outcomes.

Reporting SPARRA data outcomes

SPARRA DATA OUTCOMES
Locality
Team
Date range
Section 1	Number	Comments
No of new patients identified from SPARRA
Deceased
Live outwith the area
Live in Care Home
Currently care managed
Total number of patients remaining
Section 2
Number eligible for a care management assessment
Number of care management assessments carried out
Variance
Care management not required following assessment
Care Managed following assessment
Total number of new patients being care managed
Section 3
No of patients identified as eligible but had no assessment carried out
Not housebound attends surgery
Refused/moved away
Being assessed for long term care
Variance

A template similar to the one displayed above could be used to report the outcomes from the quarterly SPARRA list. The precise reporting process will vary in NHS Board areas. Reporting on outcomes is important to help continuously improve the system so you can provide even better care for people with complex needs.

Some Useful Contacts for advice

Janette.Barrie@lanarkshire.scot.nhs.uk
Caroline.Mitchell@lanarkshire.scot.nhs.uk
Marjorie.mcGinty@lanarkshire.scot.nhs.uk
Hazel.Towers@Lanarkshire.scot.nhs.uk
Elaine.Learmonth@Lanarkshire.scot.nhs.uk
Margaret.anne.dale@glasgow.gsx.gov.uk
Kathleen.mcguire@aapct.scot.nhs.uk
Lyall.Cameron@aapct.scot.nhs.uk
Allison.blackman@aapct.scot.nhs.uk
Sheila.buchanan@aapct.scot.nhs.uk
Laura.Kelso@aapct.scot.nhs.uk
Peter.Martin@isd.csa.scot.nhs.uk
Mandy.Andrew@scotland.gsi.gov.uk
Marie.curran@scotland.gsi.gov.uk