Background Despite large numbers of patients expressing home as their preferred place of care, the majority still die in hospital. Furthermore, in the weeks prior to death there is often a recognisable increase in healthcare activity especially non-elective admissions.

The digital healthcare team and hospital specialist palliative care team (HSPCT) have developed the Proactive Risk Based and Data Driven Assessment (PRADA) system. This inputs information from a number of sources including primary and secondary care to help identify patients who have risk escalators e.g. >3 non-elective admissions and may be approaching end of life to highlight for clinical assessment by the HSPCT.

Methods Following review and clinical assessment, the HSPCT complete a PRADA care plan which is aligned to Gold Standards Framework (GSF) and EPaCCs criteria. This is transferred directly to primary care EMIS using docman and includes suggested embedded coding e.g. GSF prognostication. The PRADA care plan includes details of advance care planning (ACP) discussions including several areas such as ReSPECT plan recommendations, preferred place of care and death and anticipatory prescribing completed as well as priorities for the patient.

Results A cohort-controlled study of those patients discharged alive, who died within 90 days of discharge, comparing PRADA with standard care (n=3730). In the PRADA group (n=114), more died but fewer in hospital (4.4% vs. 28.9% p<0.001), fewer hospital re-admissions (20.2% vs. 37.9% p<0.001).

Conclusions For patients who have been seen by HSPT and had a PRADA care plan completed this is associated with improved post-discharge outcomes which have benefits for both the patients and organisationally. We advocate joint working between hospital specialist palliative care teams and digital healthcare teams to improve patient care with consideration of informatics based digital healthcare systems.

With thanks to the late Dr Clare Marlow FRCP for her inception of the project.