All hands to the admissions pump

It’s been three years since we held our first integrated workshop on how to tackle rising admissions.

Made up of social care, GPs, community services and representatives from our local hospital, Royal Berks, one of our first analyses looked at which admissions could have been prevented internally by the hospital (for example through the input of more senior staff into assessments) and which were caused by external factors – in other words home support that was missing.

To do this, we carried out an InterQual analysis, using a US tool to categorise patients into four criteria and assess whether they needed admission.

It involved a snapshot survey of hospital admissions of five days or more over one week in May 2010.

Of 115 admissions reviews – where patients were in hospital less than 24 hours – some 25% of did not qualify for admission.

We also looked at 200 continued stay reviews – where the patient was in hospital for five days or more – and found 75% no longer qualified for acute care.

We found the internal/external split to be almost 50/50 and so we began to look at what services, had they been available in the community, would have kept those patients at home.

We also looked at the referral source for those patients who could have been cared for differently and found that GP referral was by far the commonest route (36%), followed by self-referral with the patient turning up in A&E (23%).

Because so many admissions had come via GPs, we decided to focus on giving GPs alternative options to a hospital referral.

The kinds of admissions that fell into this group were UTIs, chest infections and other, more difficult-to-influence conditions like chest pain, where the patient has to be sent to hospital to explore red flags.

But the short length of stay for most of these patients gave a strong indication that hospital wasn’t the most suitable place for them to be assessed. Our approach in response to this information was to:

⦁ introduce a new rapid-response and reablement team

⦁ create a mobile app for GPs to access information about admission alternatives

⦁ appoint three community geriatricians

⦁ introduce a service navigation team and Red Cross home-from-hospital service at the acute trust

Engaging social care

Our next ‘move’ was a result of some Department of Health funding which every PCT received at that time to increase the capacity of reablement services.

The money was for social care but had to be commissioned by health, and for our area it proved a good way of focusing minds on how integrating reablement with community services could be improved to help reduce admissions.

For the three local authorities covered by our four CCGs, the amount came to £1.9m. Of this, we invested £834,000 in community rapid response – £629,000 in rapid response and £205,000 in reablement.

Reablement is different from rehabilitation. The former is about getting a person back to the level of functionality they were at before they became ill and is more therapeutic than medical, with input from social care assistants, occupational therapists and physiotherapists, as well as health professionals, such as senior nurses. It’s about giving people the confidence to make their own meals again and to look after themselves. Rehabilitation is more focused on health, essentially getting the patient physically better. It is funded from the community services budget and occurs mainly within a community hospital setting.

What we managed to do was to join the rehabilitation and reablement services together, although the funding streams – social care for reablement, community services for rapid response – remained separate.  We set up a rapid-response team so that once a GP had referred a patient to that team, the reablement side, which involved social care input four times a day for up to six weeks, automatically kicked in.

Social care was already providing reablement services and so it was a case of us going to them with funding for an additional 300 clients, the number the InterQual audit had predicted could benefit.

Having the CCG input into how this money was spent has created a rapid-response and reablement team that GPs can call via a single number and know the patient will have a visit from the team within two hours.

There were a lot of meetings with the three local authorities covered by the four CCGs but the social care reablement and community services intermediate teams were already physically in the same building in Reading, which helped.

We phased in implementation from June 2010 with launch events to CCGs with protected time for GPs to attend, and it became fully operational in September.

Mobile app

As well as introducing GPs to the new integrated rapid-response and reablement team, which we did using information packs and case studies from the phased implementation stage, we also introduced GPs to our new mobile app.

The app was created by a member of the PCT team with the technical nous and was quite simple to do.

It is a menu of services GPs can access with the referral criteria, referral form and relevant number for that service.

Of course the rapid-response and reablement team was on the app, with its single number, but there was also information about heart failure nurses, the community respiratory team, the new community geriatricians we’d employed (see below) and a new night-sitting service.

Not all GPs have smart phones so we also made this information available on the PCT website and we send it round periodically in paper form. It was also made available to secondary and social care teams.

The new model was well received to start with by GPs but there was a very slow uptake. One problem is that if a GP has one bad experience using the service, it is passed on to the other GPs in the surgery.

We anticipated this and asked GPs at the launch to tell us of any problems and to feed it back to a named CCG person who could then discuss it at our team meetings so we could do a root-cause analysis of what had gone wrong.

One of the problems that came to light as a result was the opening times for services. For example, one GP out-of-hours service couldn’t refer patients on a Saturday morning. We responded by making services available during weekends and evenings.

We have now developed the rapid-response and reablement service so it’s going to be manned 8am till 8pm, seven days a week.

Community geriatrician

For each of the three local authority areas, we have put in place a full-time community geriatrician, each funded by the CCGs.  

What has been quite interesting is that we had anticipated their role would be direct involvement to avoid an admission. But in practice their role has been further back, rather than at the sharp end, with them creating holistic care for patients with long-term conditions who are becoming more frail, to avoid a crisis.

A challenge has been reminding some GPs they’re there, though some practices are very engaged with them.

Tackling internal factors

Last year, we decided to look at how patients who self-refer to hospital can be turned round at the door rather than becoming an admission.

Over 50% of people coming to hospital who were admitted had had no contact with their GP. So it was quite frustrating as we had invested all this money in the community but if the GP wasn’t seeing the patient, they couldn’t access those services.

The CCGs have introduced two new roles at the hospital to facilitate referral by Royal Berks to the community services – service navigation officers and Red Cross home-from-hospital volunteers.

The service navigation team is five non-clinicans funded by the CCGs whose role is to smooth the patient pathway and refer patients to the same community services to which GPs are referring.

The service navigation team has made itself known to A&E with visits and
a poster campaign, as like many A&Es there is a high staff turnover.

And when we introduced these services we did a big launch at the hospital, led by the consultants who had been integral to the service development.

The service navigation team is also working with hospital occupational therapists (OTs) in A&E and clinical decision units and has attached itself to several hospital wards with a large number of elderly patients. These OTs often have to deal with the rush of admissions in late afternoon/early evening which means the OT might not see the patient until 8pm. 

If the patient’s needs are straightforward the patient can also be supported home by one of the new Red Cross team. This is funded by the CCGs (£15,000 a year) and sits within A&E during the evenings.

These workers can take the patient home, put the heating on, ensure they’ve food in the fridge and so on and will check in on them the next day.

Outcomes

Patients have reported high satisfaction with the rapid-response and reablement service.

Savings during 2011/12 were £228,000 across four CCGs and 200 admissions avoided, pump primed by the DH funding.

Savings so far this year have come to £396,000 and 250 admissions avoided.

The initial investment by CCGs in year two was £629,000 for rapid response and for local authorities was £205,000.

It has proved very difficult to track the effects of investment.  For example, we looked at admissions by HRG codes in six areas – cardiac, musculoskeletal, gastro, neurology and immunology – but  didn’t include respiratory because there already was a respiratory arm of the four CCGs looking just at respiratory admissions and we didn’t want to double-count.

But we’ve now acknowledged that there’s so much overlap – for example someone is ‘off their legs’ but has a respiratory problem – that we’ve decided this year to put all the admission-avoidance schemes under one QIPP line and measure emergency admissions against a baseline rather than just looking at coding at the hospital.

We are also going to introduce a CQUIN into the hospital and ambulance contracts to ensure take-up of the community services.

We are seeing increasing savings, but on quite a lot of investment.

The experience has given us a  good platform for the next level where we anticipate more savings will be made and admissions will come down further.

⦁ Initiative Drive to reduce admissions by four CCGs, focusing on admissions that could have been avoided had the patient had better support at home.

Introduction of a new rapid response and reablement team and a mobile app for GPs to know which patients are suitable for services that could keep them out of hospital.

Service navigation team and Red Cross workers also introduced at local hospital.

⦁ Staff Five members of service navigation team, three community geriatricians, pool of Red Cross service workers.

⦁ Investment £629,000 from four CCGs: Newbury & District, North & West Reading, South Reading and Wokingham.

⦁ Outcomes Savings in year one of £229,000 and £339,000 in the past 10 months.

⦁ Contact ejohnston@nhs.net