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How to...avoid hospital admissions through a proactive care scheme

A new scheme has prevented 100 hospital admissions among just 200 high-risk patients in its first five months. Service development manager Julie Passmore and GP Dr Judith Reeder explain how

A new scheme has prevented 100 hospital admissions among just 200 high-risk patients in its first five months. Service development manager Julie Passmore and GP Dr Judith Reeder explain how

Proactive care is about giving patients and carers an option when they feel overwhelmed, rather than going to A&E or calling 999.

It involves identifying who is at risk of getting to a crisis situation, anticipating what might happen in the near future and deciding what can be done to best meet the individual patient's needs.

The Pro Active Care scheme set up by Nene Commissioning PBC group in Northamptonshire went live last July.

By November, some 204 patients from 12 practices had been placed in the scheme of whom 50% had avoided an emergency admission to hospital.

41222461The scheme involves a £2m investment over three years by the PCT to recruit 31 extra community nurses to free up community matrons to do more complex Pro Active Care work.

Each of the practices in the pilot receives £447 per 1,000 patients per year to take part in the scheme.

Our business case was based on the figure of a hospital admission costing £950, though we now believe the actual figure to be nearer to £1,563.

How the scheme works

Each practice designates a staff member, usually an admin person, to be a ‘tracker'.

For one or two hours a week the tracker will look at patient activities that indicate they may be an emergency hospital admission risk, such as number of calls to the out-of-hours service or number of recent GP appointments.

Patients can also be flagged up to go on the register by anyone within the practice team.

Once a week the tracker, GP, district nurse and/or community matron meet to discuss which patients should be placed on a Pro Active Care register and discuss how patients already on the list are coping and what extra services are required.

The service covers patients with all types of needs and health problems including mental health and terminal illness.

About 10 to 12 patients per practice are placed on the Pro Active Care list at any one time. Patients stay on the scheme for an average of three to six weeks, although this depends on their needs and can be longer.

Once a patient is added to the list they have a one-hour management plan assessment with the community matron.

A bespoke management plan is then drawn up and a copy given to the patient/carer so they know what to do and who to call if they need assistance.

There are a number of things that the community matron can include in a management plan depending on the patient's individual needs including:

• a medication review
• extra GP visits
• additional community matron visits
• input from the Age Concern's Little Helper scheme such as doing their shopping, checking on patient, sitting service
• social services
• additional services from other teams such as the community respiratory team for COPD, diabetes community nurses or continence advisors.

The £447 received under the service level agreement is to cover the extra work done by the tracker and the rest of the practice, including the GPs, in managing these patients.

41222464In addition to setting up the tracker system, practices also agree to send a representative along to a monthly meeting with the other practices in their pilot wave so they can discuss ideas and problems.

Wave two of the scheme began in November, adding 19 practices to the scheme and meaning the two waves will cover a population of 340,000 patients. By next year we plan to have all 61 practices in the consortium involved.

PBC group role

Nene Commissioning is made up of 62 practices in Northamptonshire covering 500,000 patients. PBC incentive payments that would usually go to practices are pooled and given to Nene Commissioning as a management allowance.

There was a history in the area of local clinicians trying to implement a similar scheme on a much smaller scale. Northampton PCT was keen to provide funding for the service but asked for Nene Commissioning to come on board as the lead commissioner in January 2008. The PCT wanted the business case, which had already been approved in principle, made more robust so that it set out rate of return and value for money. The business case showed that there would be an overspend in the first year, that the service would break even in the second year and that it would deliver savings in the third year.

As lead commissioner, Nene commissions local practices to provide the Pro Active Care service under a service level agreement which is held between the PCT and the individual practices. Nene Commissioning has responsibility to performance manage the requirements in the service level agreement.

It also commissions the work done by the PCT's provider arm for the scheme.

Northamptonshire PCT approved the business case in March 2008 and once the scheme had trust backing, a Pro Active Care board was established.

Chaired by Nene Commissioning, the board has representatives from all the partners engaged in the provision of the service, including provider services, Age Concern, Northamptonshire social services and the Intermediate Care Team. Patient representation from the Northampton LINkS has also been instrumental in developing the scheme.

Community matrons and nurses

In 2006 the three PCTs in Northamptonshire merged to become Northamptonshire Teaching PCT. Each of the three PCTs had taken a different approach to the community matron role, with each PCT giving them different roles and titles.

The Pro Active Care scheme has been a positive vehicle in allowing provider services, the matrons' employer, to iron out such differences.

This process was helped along by the PCT needing to meet a DH target at the time on the number of community matrons it had.

Pro Active Care is funded £1.08m a year by the PCT and £700,000 of this will be spent on additional nursing costs.

This will fund 31 extra community nurses (band 3 and 5) who can do tasks such as dressings, catheters and more of the basic core work that has freed up community matrons to be involved in Pro Active Care.

The posts have attracted a surprisingly large number of suitable applicants and 15 have already been recruited, trained and deployed in the first wave.


We think the scheme has definitely enabled improved communication between GPs, community nurses and social workers.

It helps to maximise the outcome of the clinical interventions GPs make by responding directly to the individual needs of patients. It also helps to target resources at the patients who most need it.

The practices that volunteered to be in the first wave were motivated by these factors rather than the money, which for a practice of 6,000 patients would be less than £52 a week.

Wave 1 are now holding training days with wave 2 and things are moving so much quicker second time around. Wave 1 pilot practices had to develop the forms and processes all from scratch.

Our work in the future will be on working with the acuiite sector to reduce excess bed-days through the Pro Active Care scheme. This will put in place the support to get patients back home and ensure they are not readmitted. This has formed the basis of our bid to become one of the national integrated care organisation pilot sites.

If we were setting this up again we would be keen to get the acute sector involved from the outset for their advice and input because, as we now look at extending the scheme to capture or recapture patients discharged from hospital, we recognise the need to work closely with them.

If you are considering setting up a scheme like this you should not underestimate the amount of time and work involved. And you need to take people with you on the journey. The outcome for us has been that our GP practices, and community nurses especially, now really feel empowered in delivering this scheme.

Dr Judith Reeder is a GP in Northampton, at a practice that was one of the first to pilot Pro Active Care

Julie Passmore is service development manager for Nene Commissioning

60 second summary Dr Judith Reader (foreground), Julie Passmore (rear) and district nurse Stephanie Chesterman Dr Judith Reader (foreground), Julie Passmore (rear) and district nurse Stephanie Chesterman Nene Commissioning Pro Active Care Case Study

An 80-year old woman diagnosed with dementia lives with her husband who is her main carer - but he is aso now in the early stages of dementia. The couple have had frequent contact with their practice's out of hours service for non-specific symptoms totalling 30 calls in three months. The tracker at the practice picks this up and they are placed on the Pro Active Care register.

The community matron carries out a management plan assessment and establishes the couple actually have good family support with their son and daughter-in-law living nearby. What is needed is a designated helper for the husband to call when he is concerned about his wife.

A laminated memory board is produced that serves as a prompt for the husband to check before phone out of hour services. It lists the names and numbers of helpers he can call under various circumstances. After this intervention the husband's contacts with out of hours care fall to one a month - an appropriate contact for a blocked catheter.

Checklist before phoning anyone

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