Trust develops a service to support and advice staff in providing place-based urgent care to frail older people, reducing ambulance call-outs and emergency attendances

Outline:

In 2016/17 our local health and care system highlighted need for improved support for the frail and older population, particularly those living in care homes in order to reduce demand on urgent care services, particularly ED attendance. This was supported by data that people in Tameside & Glossop had high ED attendance rates from care homes and a 50% admission rate for those people that did attend ED.

The Trust introduced a Digital Health service, providing patient care and access to expert advice remotely for community and primary care services. Using digital technology to enable community and primary care staff and carers to access a nurse specialist via SKYPE, for advice, guidance and care before considering an Ambulance or GP call-out. The service was initially piloted in four care homes before being rolled out across all care homes then expanded further to include;

• A contact point for palliative & EOL patients.

• Collaborating with North West Ambulance Service, responding to non-urgent 999 calls.

• First contact point for GP referrals.

Demonstrable benefits of the service include;

• Improved patient experience.

• Increased community-based care.

• Reductions in

o ED demand.

o Primary care home visits.

o Ambulance calls

Challenges:

In the UK 62% of hospital bed days are occupied by older adults, locally Tameside and Glossop had a higher than national average rate of ED attendances from care home residents and high conversion to admission rate.

Our ambition for the Digital Health Service is using modern technology to provide new means of care provision to our local population and to support primary and community care partners responding to urgent care needs for care home residents, providing person-centered care in their normal place of residence, wherever possible. Specific aims include;

• Reduce ED attendances

• Reduce unnecessary admissions to hospital for frail older people;

• Reduce the number of emergency ambulance call outs.

In addition to the benefits measured as a direct result of Digital health, other efficiencies and quality improvements have been observed, including:

• Efficiencies for the wider economy;

o Reduction in the number of GP callouts.

o Reducing the number of care home staff hours spent escorting patients to hospital. o Reduction in demand for community services (e.g. District nursing visits)

• Improved ED performance

• Improved patient experience for frail and older people

• Enabling earlier discharge from hospital for patients at the end of life

• Upskilling care home staff (e.g. undertaking patient observations)

Outcomes:

As a result of the DH Service the Trust has seen a 30% reduction in attendance at ED for care home resident patients

DH has undertaken 8,500 skype consultations since commencement and as at October 2018 has avoided;

• 1957 ambulance call outs and ED attendances

This equates to:

• c900 admissions avoided, and

• 3205 bed days saved

The health and care economy has seen reductions in community nursing home visits and GP call outs to care homes and in response to the Community Response Service; • 359 nursing visits (District nurse and Palliative Care teams)

• 2,064 GP visits

There are also quality benefits associated with the digital health service including;

• Improved patient experience (FFT results of 99.7%)

• Improved patient flow through urgent care which has resulted in the Trust being the highest performing ED in Greater Manchester against the 4 hour access standard (as at December 2018).

• All long term conditions patients with telehealth solutions are supported by DH and GP appointments and hospital admissions are avoided for this patient cohort by offering advice and guidance and commencing patients on rescue medications where required.

Spread:

The Digital Health Service originated in 2017 in four care homes where the teams were willing to work with the Trust to develop the service. We worked with partners to ensure installation of technology (including provision of tablet devices and broadband, where needed) to deliver the service.

Measurable improvements were demonstrated quickly and the service expanded to all local care homes and community response service. Throughout the development of DH, we worked closely with other departments within the Trust and other partners to develop the service and ensure the provision of safe, effective care and deliver a reduction in urgent care demand.

The DH Service potential is recognised at Greater Manchester Health & Social Care Partnership and we have been invited to be a key stakeholder in the LCO Network in GM. We continue to welcome other Trusts to learn from our experiences and were cited on the National ITV news as a service that is the essence of the NHS Long Term Plan.

Value:

The digital health service has achieved significant demand reductions for urgent care services within the Trust and for the wider health economy. These reductions in activity have delivered notional savings of £740K to the Trust and £134k for the health economy (excluding the North West ambulance service benefits).

FFT performance for Digital health, 99.7% of users would be extremely likely to recommending the service, demonstrates the qualitative impact of digital health. Digital Health contributes to improved patient flow through the Trust, managing all acute GP referrals into the medical team in the hospital, streaming patients to the GP receiving unit and ambulatory care or ED.

We also provide advice to GPs regarding more appropriate pathways and access to other services, where necessary. The service is undertaking a pilot with NWAS whereby they have access to the 111 & 999 ‘call stack’ for Tameside and respond to lower acuity patients, triaging them and arranging GP appointments or alternative transport to hospital. The service has a car to respond where necessary. Resulting in a 7% reduction in Ambulances at our ED, to December 2018. The service has taken 177 calls from the stack and prevented 73 attendances at ED and 113 ambulances.

Involvement

In order to achieve our ambition and to ensure that staff working in our partner organisations across the health and social care systems through our economic transformation programme, Care Together. We engaged as equal partners with our care home colleagues in taking forward our plan, we established a ‘Design Group’ which consisted of representatives from the following organisations and staff groups: Commissioners; Primary Care; Social Care; Community Teams; Secondary Care; Care Homes & IT.

The group met over a number of months in order to develop a blueprint for the service, with all stakeholders contributing in a truly integrated way and to monitor the outcomes of the initial pilot phase. The Design Group reported progress on a monthly basis to a clinical steering group known as the Clinical Advisory Group; and also reported performance against key performance indicators to an overarching programme board, known as Programme Leads Meeting.

Whilst the Design Group is no longer in existence the governance structure remains in place and ongoing engagement continues through these forums and the Digital Health team continues to engage with stakeholders closely through their governance structures including through the care home forum, Clinical Advisory Group and with North West Ambulance.