Dr Anushta Sivananthan, Consultant Psychiatrist and Lead Integrated Neighborhood Team Leader at Cheshire East Place (Credit: Cheshire and Wirral Partnership NHS Foundation Trust)
A data-driven neighborhood care program spanning eight care communities in Cheshire East has reduced A&E attendances by up to 48% in targeted areas.
Between November 2024 and November 2025, 3,587 residents identified as being at high risk for inpatient care or clinical deterioration received proactive support through coordinated multidisciplinary teams.
Rather than relying on hospital care, the program focused on early, coordinated community support, using data to identify patients at highest risk and enabling neighborhood teams to intervene through proactive reviews, rapid multidisciplinary input, medication optimization, falls prevention, social prescribing and practical support before crises occurred.
Dr Anushta Sivananthan, consultant psychiatrist and lead integrated neighborhood teams lead at Cheshire East Place, said: “This program demonstrates what can be achieved when neighborhood teams are trained to work proactively with residents most at risk.
“By combining strong clinical leadership, multidisciplinary collaboration and shared intelligence, we have improved continuity of care and reduced avoidable hospital use.
“The most important thing is that we help people live well for longer in their usual place of residence and, at the same time, build a more sustainable model for the future.”
Across the entire identified cohort, A&E attendances fell by 14.6% and emergency admissions were reduced by 26%. In some care communities, ER attendance decreased by up to 48%.
Case studies show the clinical impact of the approach. An 83-year-old man with complex physical health needs, recent falls and low mood received rapid physiotherapy information, co-ordinated urology and district nursing review, and referral to a befriending support centre. His mobility improved, his pain was reduced, and his mood stabilized after the intervention.
While Cheshire East’s population has increased by 5%, demand for urgent and emergency care has not increased at the same rate.
The initiative has also identified indicative secondary care cost avoidance opportunities of up to £2.8 million, including £1.2 million directly linked to reductions in A&E attendances and emergency admissions.
Using structured population segmentation and predictive risk models through the Combined Intelligence for Population Health Action (CIPHA) platform, neighborhood teams were able to identify residents at highest risk of decline and coordinate earlier community interventions.
More than 2,150 residents were identified through enhanced case-finding processes, and 450 received comprehensive integrated care interventions.
CIPHA is a secure, integrated data and intelligence platform used across Cheshire and Merseyside. It brings together information from primary, secondary, community and social care datasets to support population health management.
Within the platform, the Johns Hopkins ACG population segmentation model is used to stratify residents by complexity, risk, and predictive probability of hospital admission.
The platform is delivered locally in partnership with Graphnet Healthworking together with system partners to enable secure data sharing and intelligence at the neighborhood level.
Elsewhere in the Cheshire region, East Cheshire NHS Trust and Mid Cheshire Hospitals NHS Foundation Trust shared last month that they are continuing to optimize their shared electronic patient record (EPR) system months after launch.
Speaking at Digital Health Rewired 2026 on 25 March, Danny Roberts, CIO of East Cheshire NHS Trust, said trusts entered an optimization phase in September 2025 which will continue until June 2026, following the MEDITECH Expanse system going live in June 2025.
