Using diagnostics to enable new models of urgent and emergency care Tuesday 27 June, Warwick Racecourse
Chair's welcome address Dr Christopher Parker, Managing Director, West Midlands Academic Health Science Network
Keynote address: Delivering Acute Care Beyond the Hospital Walls Professor Keith Willett, Medical Director for Acute Care, NHS England
Demand and Congestive Hospital Failure: THE NHS HAS HISTORICALLY BEEN ABLE TO ABSORB THESE PREDICTABLE INCREASES, AND INDEED REDUCE ITS BED BASE AT THE SAME TIME. DIFFICULTIES WITH DISCHARGING PATIENTS FROM HOSPITAL IS NOW CHALLENGING THIS TREND. 8% reduction in beds and extra 5% lost as result of DToCs Average length of stay has reduced 5% Day surgery increased by 20% NHS bedstock, accounting for patients who are medically fit for discharge
Community / mental health nursing Rapid response care support Unwell patient at home Can they cope? Are they safe? Do they need treatment? Voluntary sector friend Falls team GP In & OoH s When we can t provide care or treatment in the community our NHS default is to a higher acuity, higher cost facility HOSPITAL ADMISSION 20-30% of elderly patient admissions are avoidable and carry risk
UEC Review Vision For those people with urgent but non-life threatening needs: We must provide highly responsive, effective and personalised services outside of hospital, and Deliver care in or as close to people s homes as possible, minimising disruption and inconvenience for patients and their families For those people with more serious or life threatening emergency needs: www.england.nhs.uk Mental and physical health Frail and elderly Children and young people Learning/physical disabilities We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery
Provide care as convenient for the patient as complexity of their illness allows, in the lowest acuity setting that is appropriate, and at the lowest cost for the NHS CHANNEL SHIFT - integrated 7
Modelling impact of channel shift Background: Modelling work in 2014 provided estimates of likely costs/savings as a result the following ten interventions as part of the UEC Review: Intervention Decreasing ambulance conveyance to ED Personalised Care Planning Community Pharmacy Minor Ailments Service Co-location of Urgent Care Centres with Emergency Departments Standardised Urgent Treatment Centres Increased use of Summary Care Records Extended General Practice opening hours Integrated Urgent Care Standards (111/GP out-of-hours and clinical advice) Improving referral pathways Ambulatory Care Interventions Next steps: Following review by NHS England the output/toolkit/guidance from the channel shift programme is now available www.england.nhs.uk 8
Urgent and Emergency Care right for the patient, sustainable and affordable for the NHS (tax payer) Prioritise the sickest, the best urgent care for the rest, prevent delays 9
NHS111 clinical advisory service from advise or direct to consult and complete Streaming to clinicians Improve patient information for call responders (ESCR, care plan) Greater levels of clinical input (mental health, dental heath, paramedic, pharmacist, GP) decision support, prescriptions Comprehensive Directory of Services (mobile application) Click, Call, Come In 10 Booking systems GP Connect GPs, UCCs, dentists, pharmacy smart call to make
#FutureNHS GP Access Hubs www.england.nhs.uk 13
#FutureNHS www.england.nhs.uk 14
Urgent Care facilities across the South Region A total of 129 urgent care facilities are currently operating. Of these: 12 are standalone Urgent Care Centres (standalone UCC) 8 are co-located UCCs with an Emergency Department (colocated UCC) 26 are Walk in Centres (WIC) 83 are Minor Injury Units (MIU) 15
Ambulance Response Programme Established January 2015, the ARP aims to increase the operational efficiency of ambulance services and improving the focus on patients clinical need and outcomes Nature of Call pre-triage Dispatch on Disposition up to 180 seconds more A new, evidence-based, code set NE, West Midlands and Yorkshire services New clinically focussed performance measures
www.england.nhs.uk coordinated; no consult in isolation
From life threatening to local STPs bringing the expertise to the patient Identify and designate available UEC services Urgent Treatment Centres urgent primary care, consistent, part of network Emergency Hospital Centres - capable of assessing and initiating treatment for all patients but will not hold all services Emergency Hospital Centres with specialist services - capable of assessing and initiating treatment for all patients, and providing specialist services: transfer or bypass access, 24/7 specialist network support Emergency Care Networks: 18 Connecting all services together into a cohesive network overall system becomes more than the sum of its parts
A new clear and consistent offer to the public: NHS urgent care starts to look like what the patients tell us they need, not what we have historically offered A common 24/7 access: NHS111 for all your urgent health needs Be able to speak to a clinician if needed (integrated clinical hub) That your e-health records are always available to clinicians wherever you are (GP, 111, 999, community, or hospital) To be booked into right service convenient to you Give care close to home through ambulatory care / frailty teams A 999 ambulance response based on need (clinical, conveyance) Provide specialist decision support and care through a network.. we will change patient and staff behaviour through experiential learning 21
New care models programme Julia Grace, Senior Strategic Account Manager (Midlands and East), New Care Models Programme, NHS England
We are realising the NHS Five Year Forward View through the new care models programme 1 Health and wellbeing gap Clinical engagement Patient involvement 2 Care and quality gap 3 Funding gap Local ownership National support
50 vanguards are developing new care models, and acting as blueprints and inspiration for the rest of the health and care system. 9 Integrated primary and acute care systems 14 Multispecialty community providers 6 Enhanced health in care homes 13 Acute care collaboration 8 Urgent and emergency care
The national programme is supporting the vanguards through the key enablers of their new care models 9. Communications and engagement 1. Designing new care models 2. Evaluation and metrics 8. Local leadership and delivery 3. Integrated commissioning and provision 7. Workforce redesign 6. Harnessing technology 5. Empowering patients and communities 4. Governance, accountability and provider regulation
The last year has been about developing and delivering new care models, and signs of impact are emerging
With the vanguards, we have developed the full MCP and PACS care models.
With the vanguards, we have developed the full enhanced health in care homes care model. 1. Enhanced primary care support 2. Multi-disciplinary team support including coordinated health and social care 3. Reablement and rehabilitation 4. High quality end of life care and dementia care Access to consistent, named GP and wider primary care service Medicine reviews Hydration and nutrition support Out of hours/access to urgent care when needed Expert advice and care for those with the most complex needs Helping professionals, carers and individuals with needs navigate the health and care system Rehabilitation / reablement services Developing community assets to support resilience and independence End -of -life care Dementia care 5. Joined up commissioning and collaboration between health and social care Co-production with providers and networked care homes Shared contractual mechanisms to promote integration (including Continuing Healthcare) Access to appropriate housing options 6. Workforce development Training and development for social care provider staff Joint workforce planning across all sectors 7. Data, IT and technology Linked health and social care data sets Access to the care record and secure email Better use of technology in care homes
Accountable care collaborations (ACC) Our values: clinical engagement, patient involvement, local ownership, national support www.england.nhs.uk/vanguards #futurenhs
Our challenge for the year ahead will be to cement the improvements, and spread successful new care models
Sustainability and Transformation Partnerships (STPs) will be key to the future delivery of health and care services STPs will consider how to implement (or scale up) new care models, drawing on the lessons from the vanguards. The specifics of the care models, and the mix between them, will be for the STP areas to determine. Some geographies will go further faster, with the creation of integrated (or accountable ) health systems. Accountable Care Systems will agree to: 1. Become exemplars in delivering the NHS s top priorities: mental health, cancer, primary care, UEC, elective, hospital productivity & standardisation. 2. Take responsibility for living within a combined system financial control total. 3. Act together to improve operational performance including, for example, the A&E four hour wait, referral-to-treatment times, diagnostic and cancer waiting times.
Vanguards are helping to reduce the burden on increasingly stretched A&E departments The North East Hants and Farnham (PACS) Safe Haven project at the Time Out Café provides a real alternative to attending A&E for people experiencing a mental health crisis, and focuses on helping people to develop self-management skills to break the cycle of crisis. Evaluated independently, it has been shown to have reduced acute psychiatric admissions locally by 33%. Intervention The Safe Haven Project operates 7 days a week, including bank holidays. It is located at the Wellbeing Centre in Aldershot which is accessible by public transport. Staff listen without judgement; they respect without conditions, and support those in crisis. No appointment is required and everyone is welcome. The Safe Haven is funded by NHS North East Hampshire and Farnham Clinical Commissioning Group (CCG). It is a partnership approach that has transcended traditional agency boundaries and geographical borders Impact Safe Haven has been evaluated independently by Mental Health Strategies and has been shown to have reduced acute psychiatric admissions locally by 33%. The number of visitors reporting their reason for attending as an alternative to A&E has increased from 24 in April 2014 to 70 in November 2015.
South Somerset Symphony Programme PACS: Better Local Care (Hampshire) MCP: Yeovil Aim: Yeovil District Hospital (YDH) was unable to achieve the A&E 4 hour target due to a lack of capacity to deal with urgent care needs. The AFFECTS programme was designed to bring management teams together to discuss and plan emergency admissions reduction. How: AEC: Ambulatory Emergency Care aims to treat people on an ambulatory basis as an alternative to admission for patients with ambulatory conditions that require acute care. The Complex Care Team holds a daily huddle to discuss plans for facilitating early discharge to patients who were admitted the previous day. Symphony programme: is working together with other partners to develop a sustainable high quality and integrated health and social care system. Outcome: YDH has been achieving the A&E 4-hour target consistently since October 2016 and has been one of the top five performers in the country. Non-elective admissions have flat lined in the last six months. Gosport: Same Day Access Service Aim: The goal of the Same Day Access Service (SDAS) is to reduce the strain on existing same-day services, ensuring patients who request a same-day consultation receive a call-back (or appointment where necessary) from a health professional more easily. How: The SDAS pools the same day primary care workload and workforce for the 4 practices into a single service. All same day urgent appointments for these four practices are handled by the SDAS. Most of the urgent face to face appointments are seen by nurses and 20% of the appointments are seen by other members of the extended primary care team such as a Physiotherapist. Outcome: Over 45,000 calls have been triaged by this service since January 2016 for four GP practices. 40% of the calls converted to face to face appointments. 75% of the face to face same day appointments handled by Nurses and Physiotherapists, 25% by GPs. This service has improved access to urgent primary care. High patient satisfaction rates recorded about 99.6% patients reported they were satisfied or very satisfied.
Case Study: Dudley MCP Situation: A 31-year-old woman who had a troubled childhood, and has been alcohol dependent since her early teens, became homeless. She is a frequent A&E attendee. She was registered with an out of area GP and did not take her epilepsy medication consistently. Intervention: Through joint working between the social worker and the mental health nurse, the individual registered with a GP in her catchment area. A discussion was had at MDT within the surgery, so that her situation could be improved. Outcome: The individual is now living independently, her epilepsy is much more under control, and her A&E attendances have reduced by 60%. She sees the Lye Community Project as an essential source of support, and knows she has access to professionals there without being judged.
For further information More details can be found on the NHS England website: www.england.nhs.uk/vanguards You can email the programme at: england.newcaremodels@nhs.net Or join the conversation on Twitter using the hashtag: #futurenhs
Question and answer session
Lunch and networking
Case study: Dudley Multispecialty community provider (MCP) new outcome based vision for urgent and emergency Paul Maubach, Chief Accountable Officer, Dudley Clinical Commissioning Group and Dr Matthew Banks, Medical Director, Operations, The Dudley Group NHS Foundation Trust
Optimised access to Integrated Urgent & Emergency Care Member of nationally leading collaboration of 22 CCGs for Emergency Ambulance Service Instrumental in the commissioning of England's first Integrated Urgent Care Service (Collaboration of 16 CCGs) Since 2015 Dudley UCC seamlessly integrated into Acute ED, GP OOHs and NHS 111 pathways.
Outcomes of this integration Dudley Group one of handful of Trusts to achieved 4hr wait for 2016-17 West Midlands Integrated Urgent Care Service (NHS 111) commissioned since Nov 2016 Dudley UCC streaming nurses direct 50% of all ED selfpresenting patients to UCC clinicians
Early enabler Dudley CCG Ask NHS app 1 of 4 national NHSE pilot sites for digital innovation Details of the app are now announced to all callers of NHS 111
Pilot findings to date 3300 downloads Across 500 W.Mids practices 250 call-backs from 111 clinical hub 56% of registrants under 36 years old 57% using symptom checker offered self-care or directed back to GP
Modelling admissions amenable to prevention Reactive Interventions Proactive Disease Management Other
Service usage profiling
Move to Mutualism & Patient led prevention
MCP outcome based vision Embedding innovation and large scale system re-design Significant Frail Elderly pathway offer Single Point of Access for all U&EC patient and Health Care professional telephony and referral information
Future Multi-speciality Community Provider
Question and answer session
Case study: Working in Partnership to Reduce Pressure on Urgent and Emergency Care Dr Dan Lasserson, Senior Interface Physician, Oxford University Hospital NHS Foundation Trust
Acute Ambulatory Care and the Future Hospital A/Prof Dan Lasserson MA MD FRCP Edin MRCGP Senior Interface Physician in Acute and Complex Medicine Dept of Geratology, OUH NHS FT Associate Professor, Nuffield Department of Medicine @DanLasserson
Disruptive innovation in the existing acute care pathway Hospitalists working outside the hospital walls Community based acute multidisciplinary assessment and treatment Evolving a new kind of community physician Taking the learning back into an acute hospital Improve patient and carer experience of acute assessment and treatment
What is ambulatory emergency care? Diagnosis, observation, treatment, rehabilitation not provided in the traditional hospital bed base or outpatients Needs observation periods, rapid diagnostics, decision-makers, reassessments Improved patient experience reduce negative impact of hospital admission cost-effective..
Emergency Multidisciplinary Unit (EMU) Accessible, rapidly responding, multidisciplinary diagnosis and treatment from a community setting Credible alternative to acute hospital admission Personalised acute care process, tailored to risk, patient and carer preference Platform for innovation in care models for older patients living with frailty allowing an organisation to learn
A journey of disruptive innovation in the acute care pathway Acute assessment by interface physicians in a community hospital Co-located services - Minor Injuries Unit / OOH base - Plain X-ray - Post acute care wards - 45 beds (stroke, hip #, generic) - relationship with acute Trust
Emergency Multidisciplinary Unit (EMU) Shopfloor Disciplines Nursing Physiotherapy Occupational therapy Social work Transport Medical interface capability, drawn from 1 and 2 care clinicians Rapid diagnostics for senior led decision making
Patient Flow Acutely unwell frail older adult living at home/care home Primary Care Paramedic Community team EMU referral Dedicated transport EMU assessment and treatment Home Community hospital Acute
Emergency Multidisciplinary Unit (EMU) Investigations POC bloods Na, K, urea, creatinine, calcium, glucose, blood gases, lactate, INR, haemoglobin, troponin, CRP Plain X-Ray (no cross-sectional imaging) Interface multidisciplinary team care : delivers enabling care alongside interventions traditionally delivered in an acute hospital, in settings close to home Intravenous fluid, diuresis, antibiotics, blood products, coordinating investigations Frequent assessment/monitoring (therapist, nursing, social, medical care) Care Pathways Ambulatory care Bed based care (community or acute)
i-stat i-stat Point of Care vs Laboratory controlled lab based studies Sodium i-stat V Lab (mmol/l) Line X=Y 6 Potassium i-stat V Lab (mmol/l) Line X=Y 150 5.5 145 5 140 135 130 125 4.5 4 3.5 3 2.5 120 120 125 130 135 140 145 150 2 2 2.5 3 3.5 4 4.5 5 5.5 6 Laboratory Laboratory
Aims of starting an ambulatory unit Increasing the volume and scope of acute ambulatory care at the JR site. Reducing variation in access to out of hospital alternatives Improving patient and carer experience of acute illness Care delivered outside the congested clinical spaces More time at home during periods of acute illness and recovery Supporting the strategic direction of the sustainability and transformation plan across health and social care
Oct 2015 Evolution of AAU One Interface Physician going to ED and finding patients Taking them up to the Day Hospital, assessing, treating, sending home Dec 2015 3 bedrooms on an acute geriatric ward given over to form an ambulatory unit Unit has own nursing team Feb 2016 Increase to 10 bedrooms on the ward Interface Physician takes all GP medical referral calls POC diagnostics embedded July 2016 Whole medical ward closed then re-opened as Acute Assessment Unit Increase in junior staffing Increase in footfall by 25%
POC Diagnostics to support AAU decisions and flow Abbott istat and Alinity: Electrolytes, Renal Function, Gases, Alere Afinion: CRP Lactate, Troponin, BNP New markers: Procalcitonin, LFTs, USS: AAU team undergoing FICE and FAMUS training screen for major cardiac problems, lung US, DVT, renal tract obstruction
Acute Hospital at Home (AHAH) and AAU Community component of AAU acute nurses with AAU and acute medical experience, particularly around frailty. Interpretation of clinical state Delivery of interventions Monitoring vitals, point of care blood tests
Acute Ambulatory Care and the Future Hospital POC diagnostics have released a cascade of change of processes of care more work needed to understand optimal combination for both blood and imaging. Clinical validation to understand how the tests perform in different environments and with different patient groups Calibrate care model to risk and patient and carer preference
Acute Ambulatory Care and the Future Hospital A/Prof Dan Lasserson MA MD FRCP Edin MRCGP Senior Interface Physician in Acute and Complex Medicine Dept of Geratology, OUH NHS FT Associate Professor, Nuffield Department of Medicine @DanLasserson
Case study: Emergency Ambulatory Care Redesigned - The utility of manufacturing processes in healthcare delivery Dr Josip Stosic, Consultant Critical Care and Acute Medicine, James Paget University Hospitals NHS Foundation Trust
Integration of POCT to enable AEC process optimisation West Midlands Academic Health Science Network 27/06/2017 Dr Josip Stosic Consultant Critical/Acute Medicine James Paget University Trust
Disclaimer Consultancy provision to: Abbott Diagnostics Bayer Pharmaceuticals
Unplanned Hospital Admissions are Seen as a System Failure Kaiser Permanente, Integrated Healthcare Responsive Emergency Healthcare! Certainty through modeling
Ambulatory Services NHS Current State Ambulatory Emergency Care (AEC) shown to: reduce impatient burden. Improve patient management, safety and overall experience. NHS emergency care inefficiencies cost 1.5 bil/year Associated decrease of patient LoS in one and two day admissions could save an additional 683.8 million. JPUH: Provision of limited AEC services within 32 bed Medical Admissions Unit. Poorly implemented general consensus that service didn t work.
JPUH AmbU Manufacturing in Healthcare Process Driven/Technology enablers Lynchpin for: Community integration Hospital outreach MDT enhancement
LEA Involvement: Healthcare Improvement Expertise Define value identify leverage points and target first Process Activity Mapping (PAM). Re-design work processes right person, right place, right tools, right time- FIRST TIME Target Delays/Remove Defects/destroy deviations Failure Mode and Effect Analysis (FMEA) Make performance visible
Delays Referral Supply chain Diagnostics POCT Radiology USS liaison Senior Decision Maker Task/skill alignment
Defects Outcome: Mortality/morbidity Process: Returns/readmissions Capacity/demand Work on the 90 th centile Technology
Deviations Standardise outputs Model failures: 1:200 SDM
Results Data
Reality of 2016 Enhanced intake streams: Paramedic/Community Nursing Limitation in exclusion criteria: NEW!!! NEW!!!: Chest pain and AmbU VTE service
The Future Well!!! AmbU Community OPAT AmbU elective procedures AmbU surgery AmbU community/frailty
Summary Understand the purpose Design the process Deliver the ideal state Sustain the purpose
Case study: Our experience of introducing point of care testing (POCT) into a paediatric assessment unit Dr Joanne Philpot, Consultant Paediatrician, Chief of Service Paediatrics and Dr Jenkins, Frimley Health NHS Foundation Trust
PAEDIATRIC ASSESSMENT UNIT (PAU) AT WEXHAM PARK HOSPITAL
PREVIOUS WORK TO REDUCE PAU ATTENDANCES Urgent Care Board Common Pathways Asthma nurses + The Asthma Bus Frequent flyers HOT PHONE LINE
PAU ATTENDANCES
POINT OF CARE TESTING (POCT)
THE QUESTION BEING ASKED: Would the introduction of POCT increase the speed of decision making and improve the flow through PAU? Horiba microsemi
PUTTING IT TO PRACTICE Location Connections Training What to audit Creation of audit forms Many thanks to: Julie Hart Oxford Academic Health Science Network Kerri Byrne Children and young persons commissioner (Buckinghamshire CCG) Kerry Whiting Consultant Biochemist, Frimley Health Angela Sullivan POCT Co-ordinator, Frimley Health
THE TRIAL PERIOD (20/2/17 16/5/17) Number of patients tested: 173 Audit forms created: 81 completed: 61
RESULTS Faster patient flow: 87 (82% of 106) Early discharges?earlier Abx administration + admission No effect: 19 Awaiting bloods/lp/ecg Unknown: 67
New way of working CONCLUSIONS AND MOVING FORWARD Evidence POCT enables faster decision making and, therefore, patient flow Business case to Frimley Health NHS Foundation Trust Difficult to show cost efficiency BUT improved patient flow = improved patient care
Question and answer session
Refreshments and break out sessions
Chair's closing address Dr Christopher Parker, Managing Director, West Midlands Academic Health Science Network