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How to: save £450K with a whiteboard, mobile phone and a chequebook

Challenging the way things have always been done can reduce admissions of patients with long-term conditions and reap savings for practices, writes Dr Tom Debenham

Challenging the way things have always been done can reduce admissions of patients with long-term conditions and reap savings for practices, writes Dr Tom Debenham

The team at Claremont Medical Practice in Exmouth, east Devon, has been overseeing its own hospital services budget for two-and-a-half years now.

Having developed an integrated nursing team through PMS (where there is no difference between the practice and community nurses or healthcare assistants, just one big team of 14 to provide the nursing services for 10,650 patients), we thought PBC was an ideal way forward to help deliver better care in a local environment for the patients. We believed in the principles of service redesign and that chronic disease management was the way forward to reduce hospital attendances, both outpatient and inpatient, in the future.

In the first year (2004/5) we had monthly half-day away days with our team and looked carefully at our budget and the opportunities it offered. Two-thirds of our budget was spent on emergency admissions and we thought this was an obvious area to look at to develop savings and deliver better care. Patients were very keen to be kept nearer home and out of hospital if possible.

We approached East Devon PCT with a plan to employ an extra nurse for 20 hours a week, and a social worker seconded from the local authority, also for 20 hours a week, at a total cost of £30,000 a year. We wanted to add the extra hours to the team of nurses rather than create one post whose sole responsibility was admission avoidance (as in the modern matron role). This was vital to the success of the project. Admission avoidance was a team issue and involved all the doctors and nurses.

We also discussed the issue of trust with the PCT. It was aware we were doing something different and was very supportive. The PCT also supported the idea of an ‘invest to save' principle and gave us the funds not only for the extra staff time but also £30,000 to support a PBC lead in the practice, management time and backfill for locums for meetings.

The first year also involved engaging all the doctors (six partners, three associates and a GP registrar) in the new way of working. Instead of admitting patients to our local DGH, they were encouraged to do something different for that patient. An understanding that each admission cost our budget £1,500 helped!

A cheque for this amount was distributed at an early meeting with an acute admission referral letter to make the financial side real. The clinician was asked to ring the integrated nurse on their mobile phone before making the decision to admit, to see if there was any possibility of more local care being provided. Those options included ‘rapid response', intermediate care, the local rehabilitation unit or our community hospital.

At the end of the first year the team thought this project was worthwhile pursuing, although the results were inconclusive and therefore savings achieved were minimal. We agreed to proceed but recorded that the savings had to be realised to offset the extra work and meetings the project required.

As the doctors became more familiar with the process, they contacted the final local option (usually intermediate care) themselves and this allowed the nurses to address the issues of assessing the needs of the perceived at-risk patients.

We looked at many models of how to find these patients but found no better ways than clinical suspicion and word of mouth. We didn't find any ‘revolving door' patients despite looking for them. We put this down to the high-quality care we offered to our patients in the past.

Out of this came the idea of a whiteboard to track these patients. The board is on the wall in the nurses' room and is used to create an ‘at risk' register that gives a red, amber or green status, using nurses' subjective criteria, of any patient that doctors or nurses are worried about. This mainly means individuals with a long-term condition who are potential admissions to the local DGH.

Once identified, the patient will be assessed as soon as possible using a single assessment process form, which reduces duplication if other agencies are called in to help.

Once on the board the patients will be tracked and the nursing team will discuss all the patients in the various categories at least once a week. After moving from red to green they will then be removed from the board. The idea is that this is a dynamic process and the at-risk caseload is not a static list of patients. One-quarter of our patients are over 65 so we have a lot of morbidity to consider. On average, there are about 40-50 patients on the board at one time.

Clear lines of communication

Another role of the nursing team is to monitor the admissions to the DGH. We get a daily email from the hospital to inform us of the last 24 hours of admissions and try to get any patients out of the hospital and back to our locality as soon as possible (discharge within 48 hours only attracts 40 per cent of the tariff as a cost to our budget). Clear lines of communication with the hospital discharge co-ordinator (a PCT employee) and intermediate care were essential to aid the process.

Early in the project we identified a need for medicines management and were successful in our bid for a pharmacist for one day a week, at a cost of £10,000 a year. This has been key to supporting people with long-term conditions and has already prevented two readmissions due to medication issues, and helped cut costs on our prescribing budget.

The pharmacist receives referrals from the nursing team and doctors and will visit patients in their own homes.

Our patients definitely approve of this initiative. One of our fears was that patients might feel they were ‘denied' hospital admission, but this was never encountered.

The clinicians were initially concerned about the potential extra ‘risk' of keeping someone at home (‘for financial reasons') and the extra workload. However, as the savings mounted up, this helped to keep the team motivated.

By the end of year two we had realised a £450,000 saving on our overall budget, most of this coming from the 15 per cent reduction in emergency admissions.

The PCT ‘saved' £220,000 in reduced admissions, the practice received £150,000 in savings to keep, plus the £80,000 of management and staff costs, the latter of which also included £10,000 for a dermatology initiative. This shows, in my opinion, what a good investment it was for the PCT to have made.

In year three (2006/7) the project is ongoing and the 15 per cent reduction in admissions is being maintained, as compared with a 6 per cent increase in admissions nationally.

We have just completed adding a new room to our main premises for the nurses to work out of (funded from our savings) with the plan to have an electronic white board so we can distribute a list of our at-risk patients to the local out-of-hours provider. Also, our branch surgery has two more consulting rooms to allow more local provision of outpatient services.

Our plans for the future include consolidating the role of the locality commissioning board to involve all of our local practices and working closely with the new PCT (Devon PCT) to try to facilitate the local provision of services.

The key message is that if you are not happy with the results you are getting for your patients, try something different – it may create a win:win for all parties.

Dr Tom Debenham is a GP and PBC lead at the Claremount Medical practice in Exmouth, Devon

60 second summary

The aim: Reduce admissions of patients with long-term conditions through better use of local services

The initiatives:

• £1,500 dummy cheque attached to acute admission form to remind GPs of cost of such referrals and to think of local alternatives

• GPs phone integrated nursing team on mobiles to discuss alternatives

• Nurses case-manage a ‘live' at-risk register on a whiteboard with patients moved from red to amber to green status

• Daily email from DGH on admissions in past 24 hours

• Attempt to discharge patients within 48 hours for reduced tariff cost

• Pharmacist takes referrals from nurses and GPs to improve medicines management, also visits patients in own home

Preparation time: One full year lead-in time to challenge ‘the way things are done'

Staffing required: £30,000 for extra nurse and social worker hours; £10,000 for pharmacist time

Management: £30,000 to fund management and required

Resources required: meeting costs

Results: Emergency admissions reduced by 15 per cent

Total savings: £450,000 for 2005/6

Savings kept: £150,000 by practice

Contact: Dr Tom Debenham email

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