In commissioning basic home care to keep vulnerable patients out of hospital, Nottingham North and East PBC consortium turned to the Red Cross. PBC manager Hazel Buchanan explains.
All too often, the elderly, frail and vulnerable are admitted to hospital with a minor illness because they can no longer cope at home. And yet the stress and upheaval of a hospital stay could be prevented if someone was available to provide them with basic home care.
At Nottingham North and East Consortium (NNEC) we have enlisted the help of the British Red Cross to bridge that care gap. Now patients in need of extra support are able to cope with minor conditions at home thanks to our Crisis Intervention Community Support Service (CICSS). And they are not the only ones to benefit: non-elective hospital admissions have reduced since the scheme began in July 2009, saving an estimated £200,000.
We started to look at how we could offer basic home care to support the frail and elderly in November 2008. Our PBC consortium – which covers 21 practices and serves a population of 133,000 – has an emergency care task and finish group. The group was established to look at how to improve the quality of emergency care referrals and to explore ways to prevent unnecessary admissions. The group, which is made up of clinicians, PBC staff and patient representatives, found there were few resources or agencies available in the community to offer vulnerable patients care based on social need. A stay in hospital was often the only option, when sometimes all that was required was a regular home visit and low-level social care. While no figures were available, we were told by GPs that they were struggling to get low-level support for patients.
Step-up beds were considered as an option but existing facilities in our cluster were, and remain, very limited and there was no interest in the market. Then an emergency care group member told us the local British Red Cross was providing a service for vulnerable patients being discharged from secondary care called Homes from Hospital. We learned the organisation was also keen to offer a similar service to prevent them being admitted in the first place.
In January 2009 we met members of the British Red Cross team and were impressed with the Homes from Hospital service.
The organisation wanted to deliver a community intervention crisis service where vulnerable patients would be visited by a member of their team. Patients would receive support with individual basic care needs, which could be anything from shopping and light meal preparation to organising ongoing care with social services.
The proposal was given the green light by the PBC consortium and we asked the PCT if it would approve the scheme. Nottinghamshire County PCT has always supported us in our efforts to bring care closer to home and had already backed such projects as our successful and popular community pain service. It is also interested in ways to reduce hospital admissions and encourages us to come up with innovative solutions, so it was keen to let us trial the service. It approved the scheme and we received £151,000 from the PCT's innovation fund to run a one-year pilot project across our PBC area.
The task and finish group headed the project and I was project manager. We worked closely with the British Red Cross in defining processes and procedures that were workable within the time constraints, and agreed what would be rolled out after we went live.
The contract included such requirements as ensuring CICSS would visit an individual within an hour of a referral and give feedback about progress to the patient's GP. Staff would ask clinicians referring patients to CICSS whether their only other option would have been hospital – which gave the consortium referral reduction figures.
For the British Red Cross the big challenge was to meet the PBC's six-week deadline to launch the scheme so any initial problems could be ironed out before winter pressures kicked in. This was tough as there was no other service like it in the county. But the organisation was fantastic at getting things moving, recruiting the CICSS team to deliver the service and organising their training.
So by July last year, the service was up and running.
The service is a short, intensive programme of care that aims to give long-term solutions for those in need of support. Any vulnerable person over 18 can be referred by their GP, practice nurse, community matron or district nurse, providing they live within our PBC area and do not require purely medical care. Our COPD and heart failure nurses, out-of-hours and intermediate care providers and the ambulance service can also refer patients.
Patients are visited by a British Red Cross community worker. During a two-hour assessment, staff will discuss the patient's overall needs, then put together a four-week individual care programme. When carrying out the assessment it is important to establish the individual's needs while ensuring they feel in control. So that patients do not feel help is being forced upon them, community workers discuss with them how they are going to co-ordinate their care.
A typical patient might be someone with a chest infection. The community worker will prompt the patient to take their medication, make sure their condition is not getting worse, ensure they are drinking and have access to food, find out whether they need their shopping done. The CICSS is about enablement and if there is anything they can't do to meet an individual's needs, they will refer them to the necessary agencies, such as a handyman or social services.
Since the service began, it has supported 209 patients at a cost of about £300-350 per referral, but we expect costs to fall if the number of referrals increases. So far about 58% of referrals have prevented an admission. We have seen a reduction in our non-elective admissions, but it is too soon to say whether these are directly attributable to the CICSS. In the first six months we have achieved about £200,000 in savings, but this is a crude figure and we need to run the service for at least a year to evaluate it effectively.
The service has improved care for patients by providing them with social support, improving medicines management and boosting their general wellbeing. Just the fact that they are seen at least once a day is beneficial to their care as if there are any problems the CICSS can immediately contact a clinician.
Initially there was a degree of scepticism from GPs about whether CICSS would work. But since they have seen the benefits, many clinicians have given us great feedback and believe it helps patients. GPs also say the service has reduced their workload because CICSS staff not only visit patients, but also refer when necessary to other agencies.
One of the key successes of this scheme is flexibility, which goes back to the values of the British Red Cross. Staff have a ‘can-do' attitude and are not hampered by red tape and bureaucracy. They are there to do one thing – to help an individual through a crisis so they don't have to go into hospital, which could be more detrimental to their quality of life. CICSS staff will do what they can to achieve this and if there is something they can't do, they will find someone who can.
Working with such a well-respected charity opens many doors. The British Red Cross has a wealth of knowledge of the agencies and services offered in the community, so is able to support whatever needs are identified. And because the organisation is noted for being reliable and trustworthy, its staff are welcomed by patients who may not want to see staff from other agencies.
An example of the charity's commitment was during the recent snow. In our cluster there are some neighbourhoods with huge hills, and the roads became impassable for normal cars. CICSS was able to call on the British Red Cross Emergency Response Unit, which provided 4x4 ambulances ensuring everyone was seen every day and that they were warm and had food.
To any other PBC organisation considering emulating our scheme, I would stress that it is vital to get the right provider. They must be committed to going that extra mile and they should have a workforce that supports the service's values and vision.
Because CICSS is a pilot scheme we're still looking at ways to enhance the service. For example, our primary care pharmacists now visit people's homes to carry out medication reviews through referrals from CICSS. The PCT has been very supportive, letting us take the lead and recognising the service's successes. Although GPs also appreciate CICSS, they are used to seeing services come and go. So to keep their positive attitude, we need to continue to demonstrate the service's value to keep it running.
Six months into the pilot we have commissioned an academic professor in medicine for healthcare of the elderly to carry out a formal external evaluation. We expect to get the results this summer and will present our findings to the PCT in the hope it will commission a CICSS model as an ongoing service, and even expand it across the county. In so doing we hope to support more individuals in crisis.
We believe this service can make a genuine difference to people's quality of life, offering support in a way that respects their needs while preserving their dignity.
Hazel Buchanan is PBC support and development manager for NNEC, Nottingham
Initiative Crisis Intervention Community Support Service (CICSS) provided by British Red Cross to enable vulnerable patients to cope with a minor condition at home. Support includes food preparation, shopping, ensuring they are drinking fluids and taking medication
Policy link White paper Our Health, Our Care, Our Say
Estimated savings £200,000 in six months
Benefits Prevented hospital admissions for 58% of users. Gives GPs and other clinicians a more suitable option to refer to with ongoing feedback about a patient's progress
Contact Hazel Buchanan, NNEC support and development manager, email email@example.com
CICSS – a GP's perspective
Dr Tony Marsh, clinical lead for Nottingham North and East PBC cluster and a GP at Netherfield Medical Centre, is impressed with how much CICSS has benefited patients in his community.
He says: ‘Our PBC cluster recognised that sometimes patients were admitted to hospital not because they were extremely ill, but because their moderate illness had made them so frail that they were unable to cope.
‘We felt this was not only using up resources but bad for patients. As well as being a distressing experience, we know that an admission to hospital often causes people to deteriorate in terms of how well they function at home on their own.
‘The British Red Cross was also aware of this problem, so we decided to work together to help keep people out of hospital.
‘Now if I see someone who I feel needs urgent but temporary extra support at home all I have to do is to ring CICSS and give staff the details. They will arrange a prompt visit and report back to me about what services the patient is receiving.
‘It's a relatively easy process and often simpler than referring someone to hospital or social services.
‘My experience of working with a third sector organisation has been that the service is flexible and staff have the skills and experience to solve problems. I've also been pleased with both the quality of the service and the feedback we have had about a patient's progress. That timely feedback is often missing when patients are referred to secondary care.
‘Patients have also welcomed CICSS and I've heard nothing but gratitude and praise. GPs have given it their universal support, noting its value at our practice forum, where all the cluster practices meet. We feel that the service has significantly reduced hospital admissions, although this is difficult to quantify as there are so many variables involved.
‘I hope the evaluation of CICSS later this year will confirm the gut feeling of GPs that this is a useful scheme. Of all the services we've commissioned this is the one we feel has the best feel-good factor, with good feedback from both patients and referring doctors.'
CICSS patient information leaflet CICSS referral pathway The Red Cross team