Collaborative Working to reduce hospital admissions Dr Firdaus Adenwalla Annette Davies Beth Griffiths
Ageing population A third of babies born in the UK in 2013 are expected to live to be a 100. (Office for national statistics- UK)
National records of Scotland
The National archive ONS.gov.uk
Monitor (NHS England, 2013) The NHS was developed to provide largely episodic care. It generally treats people when they fall ill. But this care model will not be sufficient to meet the health needs of a growing, diverse and ageing population with high rates of chronic diseases, obesity and mental health problems. A 21 st century NHS will need to deliver care that meets the health needs of today and focuses more on preventing illness and supporting individuals in maintaining active and healthy lifestyles. If the founding principles of the NHS universal access to excellent health care, free at the point of use are to endure for future generations, then NHS staff, politicians and the public will need to work together to develop new care models for the NHS and new ways of working. It is up to all of us to make this happen.
Welsh Government Case for Change Problems Demographic projections of an increasingly older population, both in numbers and as a proportion of the general population, with a significant increase in the very elderly those aged 85years and over The increased incidence of chronic conditions based upon an increasingly older population and poor lifestyle choices The increased longevity also brings increased complexity of cases with multiple co-morbidities The increased incidence of dementia that longevity brings a 30% increase is projected in Wales in the coming decade alone. In some rural areas the numbers are projected to increase by 44% Solutions Person centred services delivered as a single model of service delivery provide better quality care and result in improved outcomes There is a need to provide co-ordinated, single service responses to promote and protect what can be fragile independent living.
Neath Port Talbot Demographic breakdown 2015 Total Population 140,490 2015-20% 65 years and over
Rockwood Clinical Frailty Score January - December 2015 123 459 221 1-3 very fit 4 vunerable 5-6 mild/moderate 7-9 severe/very/terminally ill 447 Frailty in the community
So what do we do? Day hospital Community Community hospital Right care at the right time in the right place Clinic Acute hospital
If the place is not right... Delirium Falls Hospital acquired infection Continence Incontinence Loss of muscle strength Dependent Delayed discharge Loss of confidence, independence, further de-conditioning
How are we doing it? Acute hospitals Ambulance service Day hospital Care homes Acute Clinical Team Local Authority GP, District nurses
The Acute Clinical Team (part of Neath Port Talbot Community Resource Team)
Common Conditions Aspiration pneumonia/chest Infection/LRTI/COAD Anaemia Falls Dehydration/AKI Urinary Tract Infection Worsening Heart Failure (Heart failure nurse + Cardiologist) End of Life Fast Atrial Fibrillation Cellulites Acute Confusion Conditions requiring long term IV antibiotics Electrolyte Imbalance Lots of Cancer (diagnosed and undiagnosed)
Mrs MW 87 years Seen by care worker on routine visit - concerned- not well abdominal pain- called 999 Paramedics Strong smell of urinerang ACT- can you respond? ACT + MSU. CRP- 136 (57). WCC- 21 (10). Poor fluid intake. Dehydration - IV fluids and IVABX Constipated- enema (7 hospital admissions in previous 12 months)
Nursing Homes Most frailest of the frail Referrals increasing Team work well with NH staff and GPs End of life (work with GP, family, district nurses) Important to receive early referral
REFERRAL PATHWAY TO THE ACUTE CLINICAL TEAM (ACT) Referral Criteria There is a new symptom or worsening of an on-going problem requiring a same day assessment. For example: < 700ml per day oral intake over 48 hours that has not responded to local measures multiple episodes of vomiting and/or diarrhoea over 24 hours care home staff suspect dehydration continues to be unwell despite 48 hours of antibiotics for UTI, chest infection, cellulitis new onset of difficulty in swallowing or aspiration
Life is really simple, but we insist on making it complicated Confucius
75 year old Nursing Home resident. GP was called- Chestydrowsy. Not well. Spoke with family- escalation future plans CRP- 429- (improved to 92) IV antibiotics ACT Probably aspirated Creat- 504- improved to 104. IV fluids Recovered- but subsequently further aspiration- No active treatment- Died peacefully in the Nursing Home
Reduced Admissions (ref: national Wales Information Service)
Care Home admissions in Neath Port Talbot between April 2013 and May 2016 (ref: Joint Partnership Board)
Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Average home care hours per month (ref: Joint Partnership Board) 70 60 50 40 Average Home care Hours per Client per Month 62.3 54.9 47.6 30 20 10 UCL Mean LCL 0 Months
Learning points to date Capable of tackling problems that one sees in hospital. Advanced practitioner led with good senior medical support Seven day working (extended hours) Urgent access to personal care Key ingredient is Trust- closely linked with clinical governance Break down barriers between stakeholders Rapid access to investigations Blood and Radiology Close links with care homes, GP, Paramedics...
Ingredients for successful integrated working Respect Trust Reciprocity Communication Accountability/responsibility Clear Governance Time
Challenges and short comings (Ambulatory care perspective) Transport,Transport, Transport Access to urgent radiology Often unable to take new referrals after 5pm (Staffing issues) Having to refuse new referrals due to lack of staff Urgent access to specialist clinics Need to improve links with A&E/Admission Units Time taken to get blood results POC testing Strengthen links with paramedics and Advanced Paramedic Practitioners. Strengthen links with microbiologist and pharmacist for OPAT Midlines/PICC insertion at home
Thank you for listening Any questions? Annette.Davies@wales.nhs.uk Firdaus.Adenwalla@wales.nhs.uk E.D.Griffiths@swansea.ac.uk
Supplementary slides if needed to respond to questions
Acute Clinical Team Activity January 2015 December 2015 Total Referrals 1254 Average Age 80 Hospital Admissions 151 (12%) Intravenous Treatments 36% Average case load 35 patients ( virtual ward) Average length of stay 10.2 days
ACT and Ambulatory care Assessment, management and monitoring of abnormal cardiac rhythms- fast AF, bradycardia. Assessment and management of worsening confusion Assessment and management of SOB (not acute), worsening CCF Assessment and management of suspected DVT (immobile patients)
ACT and Ambulatory care IV antibiotics for Cellulites, COPD Exacerbation, Bronchiectasis, CAP, Aspiration, UTI, infected foot ulcers, osteomylitis. IV/SC fluids for AKI, electrolyte imbalance, dehydration, Impaired swallow. IV drugs for hypercalcaemia of malignancy, high INR, hypocalcaemia, heart failure
Who we are Nurse Led service Clinical lead/advanced Practitioner Consultant Support Advanced Practitioners (Nurses x 3) Trainee Advanced Practitioners (Nurse x 2, Paramedic x 2) Sisters x 3 Staff Nurses and Paramedic Health Care support workers Administration support
What we do 7 day working 8.30-10pm Providing a nurse practitioner led rapid assessment service which is responsive and reflexive. It can deliver holistic clinical interventions that successfully manage problems that would traditionally have required a hospital admission or a longer hospital stay.
Mrs CR 96 years old, she lives in a Residential Home Home referred to GP- acute swallowing difficulties & off legs Paramedics called ACT Seen by ACT same day. Acute stroke Bloods - infection, AKI Imp aspiration + stroke 48-72 hours IVABX & Fluids+ spoke to family DNACPR, End of life- RIP.
Referral Source 29 14 79 58 183 86 805 GP Consultant Hospital Nurse Paramedic Pharmacist Therapist Nursing Home
Sam s story http://www.kingsfund.org.uk/audiovideo/joined-care-sams-story