Early Intervention TeamResponding to Urgent and Emergency

Care in West Suffolk

Context

• Increasing ED attendances (DOH, 2014)• Growing older population and number of patients with

complex conditions (West Suffolk CCG)• Poor outcomes:

– long hospital admissions (Alzheimer’s Society 2009)– English and Paddon-Jones (2010) reduced muscle

strength after hospital stay in older people• Early Intervention Team (EIT) (Occupational Therapy

and Physiotherapy) based in ED and AMU Monday to Friday 8:30- 16:30

• Referrals on to Social Services and voluntary sector

Drivers for change

• Needed changes to patient flow and admission avoidance (NHS Confederation 2016)

• Consultants requesting EIT at weekends and later on weekdays, as patients are not requiring acute medical treatment

• Better coordination for patients with frailty (BGS and RCN, 2015)

• Reduce hand- offs, improve rapid access to services

• Push model out into the community, challenge ED attendances

Starting point

• Initial trial of extended hours and voluntary weekend working in ED and AMU highlighted able to discharge patients but needed support from Social Services

• Task and Finish Group with key partners • Applied for funding from West Suffolk CCG

to enhance current team

Opportunities identified

• Integrated working between health, social care and voluntary sector (NHS Five Year Forward Plan, 2014; Oliver et al 2014)

• Support from geriatricians, need to link up with community services

• Improved patient experience, promote reablement • Reduce conveyance • Cost avoidance for length of hospital stay, improve long- term

health (Alzheimer’s Society, 2009; English and Paddon- Jones 2010)

• Increased role of AHPs

Aims and objectives

• Phase 1 November 2013 – Reduce acute

admissions through admission avoidance in ED

– Reduce length of stay on AMU

– Integrated working

Aims and objectives

• Phase 2 November 2015– Community admission avoidance– Reduce ED conveyance – Integrate with Admission Prevention nursing service – “The clinical audit at West Suffolk Foundation Trust in

December 2014 identified that a significant proportion of the admissions were underpinned by frailty with respiratory, urinary tract infections and falls being a trigger’” The West Suffolk 2014/15 Winter Review

Method and approach

• Phase 1 November 2013 – Extended hours, 7 day service– Integrated team, wraparound service

• Therapies (West Suffolk NHS Foundation Trust)• Age UK Suffolk• Suffolk Social Services• Dementia liaison nurse (Norfolk and Suffolk NHS Foundation

Trust)• Carers (Crossroads East Anglia)• Access to Geriatricians

Method and approach

• Phase 2 November 2015 – Extension of integrated team:

• Colocation of Admission Prevention Nursing Team (Suffolk Community Healthcare)

• Reablement support workers (carers) in- house• Suffolk Family Carers link worker

– Promotion of team to GPs, Ambulance Service, Social Services, community health teams, housing associations, hospice

Successes

• Improved communication, integrated team in same office

• Shared learning• In ED became part of the core team, improved

relationships and respect• More power • Increased referrals in ED and increased

discharges • Discharge to assess model• Reablement focus

Barriers

• Different IT systems and governance agreements

• Delays in handing over for on- going care• Delays in Continuing Healthcare • Office space • Out of county patients in ED

Service outcome measure

• EIT intervention impact score results for patients seen in January 2016 in ED, CDU, Fracture clinic and AMU

Category Descriptions Frequency Percentage0 - No change 12 7.9%1 - Unavoidable admission (Medically unfit) 30 19.9%1a - Unavoidable admission (No intermediate care) 1 0.7%1b - Unavoidable admission (No Care package) 1 0.7%1c - Unavoidable admission (No respite bed) 0 0.0%1d - Unavoidable admission (Vulnerable adult) 0 0.0%1e - Unavoidable admission (No transport) 0 0.0%1f - Unavoidable admission (Unable to contact home) 0 0.0%1g - Unavoidable admission (Patient anxiety) 0 0.0%2 - Facilitate safer discharge 39 25.8%3a - Admission avoidance 62 41.0%3b - Admission avoidance (Intermediate care) 5 3.3%3b - Admission avoidance (Respite care) 1 0.7%3b - Admission avoidance (Hospice) 0 0.0%Total patients 151 100%

Results and evaluation

• Exceeded KPIs in first year for ED and AMU – December 2012- April 2013: 360 avoided admissions

and early support discharges – December 2013- April 2014: 777 avoided admissions

and early supported discharges – December 2014- April 2015: 971 avoided admissions

and early supported discharges – December 2015- April 2016 1559 patients seen in the

community, 804 avoided admissions and early supported discharge

Results

• Qualitative- Positive feedback from patients, families, health and social care providers

• Improved wraparound service, holistic assessment/ comprehensive geriatric assessment. Efficient “one- stop shop”, rapid access

• Cost avoidance for reduced conveyances, health promotion (£1078 average admission tariff)

• Need further promotion to GPs and Ambulance Service to increase community admission avoidance

Key learning points

• Team adapting to change• Managing expectations• Coordination • Data collection from different organisations• Promotion to public and primary care • Value of AHPs in urgent care

Plans for spread

• Further integration with GPs/ Ambulance Service • AHPs to triage in ED • 24 hour reablement support worker service • Entered HSJ Awards• NHS England (2016) rehabilitation

commissioning guidelines • Promotion to patients to not attend ED • Training opportunities- ? X- ray requests ?

Prescribing

Follow us!

• Twitter: @WSH_EIT • Youtube: https://www.youtube.com/watch?v=m76CkAn7JC4 • Website:

http://www.westsuffolkccg.nhs.uk/clinical-area/clinical-workstreams-and-current-priorities/integrated-care/early-intervention-team-eit/

Thank you!

References

• Alzheimer’s Society (2009) ‘Counting the cost: Caring for people with dementia on hospital wards’ [Internet] Available at: https://www.alzheimers.org.uk/site/scripts/download_info.php?fileID=787

• British Geriatrics Society and Royal College of Nursing (2015) Fit For Frailty [Internet] Available at: http://www.bgs.org.uk/index.php/fit-for-frailty

• College of Occupational Therapists (2015) Urgent Care: The Value of Occupational Therapy [Internet] Available at: https://www.cot.co.uk/sites/default/files/general/public/Urgent-Care-report-2015.pdf

• English, K.L and Paddon- Jones, D (2010) Protecting muscle mass and function in older adults during bed rest. Current Opinion in Clinical Nutrition and Metabolic Care 13(1) p. 34- 39

• NHS England (2015) What actions could be taken to reduce emergency admissions? [Internet] Available from: http://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions.pdf

• Kings Fund (2010) Avoiding hospital admissions [internet] Available from: http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

• Lord- Vince, H et al. (2014) The need for a 7- day Therapy Service on an Emergency Assessment Unit. British Journal of Occupational Therapy 77 (1) 19- 23

• Nhs Confederation (2016) Growing Old Together: Sharing new ways to support older people [Internet] Available at: http://www.nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Growing%20old%20together%20-%20report.pdf

• NHS England (2016) Commissioning Guidance for Rehabilitation March 2016 [internet] Available from: https://www.england.nhs.uk/wp-content/uploads/2016/04/rehabilitation-comms-guid-16-17.pdf

• NHS England (2014) The NHS Five Year Forward View [internet] Available from: https://www.england.nhs.uk/ourwork/futurenhs/

• NHS England (2015) What actions could be taken to reduce emergency admissions? [Internet] Available from: http://www.england.nhs.uk/wp-content/uploads/2014/03/red-acsc-em-admissions.pdf

• Oliver, D. (2015) ‘Integrated services for older people- the key to unlock our health and care services and improve the quality of care?’ Journal of Research in Nursing 20 (1) 5- 11 Available at: http://jrn.sagepub.com/content/20/1/5.full.pdf+html

• Oliver, D, Foot, C and Humphries, R (2014) ‘Making our health and care systems fit for an ageing population’ The King’s Fund [Internet] Available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/making-health-care-systems-fit-ageing-population-oliver-foot-humphries-mar14.pdf

• Wilson, A et al. (2015) Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]:a mixed-methods case study approach. Available at: http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0020/151337/FullReport-hsdr03370.pdf