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Trust creates the high impact users group to work with patients who regularly visit emergency department, reducing attendances and admissions up to 80 per cent

Challenge

    • Patients known as “high impact users” attend the Emergency Department (ED) up to sixty times per year
    • 800 patients per year are ED high impact users
    • ED staff reported that this cohort consume large amounts of time and resources, and can be distressing for staff and other patients
    • Reduce repeated ED attendances and hospital admissions

Action

    • Redesigned the ED pathway to enhance patient experience
    • Collaborated with a wide range of groups across acute trusts, primary care etc
    • Created a “High Impact User” group, comprising of ED Consultant, ED Matron, GP and Clinical Nurse Specialists
    • Identified the ten most frequent attenders for each month and managed those cases by making individual patient support plans, risk assessment etc

Result

    • Improved patient and staff experience
    • Reduced all primary mental health attendances by 30% on average
    • Resulted in staff reporting high levels of satisfaction with the use of support plan
    • Up to 80% reduction in ED attendances and admissions
    • Resulted in up to 80% savings from tariffs

* Please describe the challenges or problems your solution set out to solve.

In UHBristol, patients known as “high impact users” attend our Emergency Department (ED) very frequently, up to sixty times per year each. These patients reported that increased ED use is associated with personal/health/housing/mental health crisis: they come to ED because they have nowhere else to turn.

ED staff report that this cohort consume large amounts of time and resources, and can be distressing for staff and other patients. We wanted an innovative system-wide approach to this problem which would improve patient experience, support staff, and reduce ED attendances and hospital admissions therefore improving value and efficiency. 

* Please describe the actions you took to achieve your result.

Involvement

Coproduction with patients using service user feedback:

• Increased ED use represented crisis

• Did not “like” coming to ED repeatedly

• “nowhere else to turn”

• Welcomed an alternative pathway.

Other parties involved in set-up and representation on the working group and spread

• Primary care

• CCG

• Ambulance service

• Police service

• Mental health trust

• Voluntary/charity partner agencies

• Neighbouring Acute Trust

• Academic Health Network

We can demonstrate strong partnerships across and beyond the hospital, and we believe we are the first group to collaborate with such a wide range of groups across acute trusts, primary care, mental health, housing, social care, the voluntary sector and policing for this very vulnerable patient cohort.

Value:

We can demonstrate that our project has simultaneously delivered financial savings and improved patient and staff experience.

Baseline – what we found:

• 800 patients/year are ED high impact users

• Annual mortality rate 15%

• Mostly preventable deaths

• Average age of death in the mid-thirties

• Mental health problems and/or drug and alcohol problems present in almost all patients

• “Super-users” had up to 60 attendances/year

• “Super-users” generated costs of up to £30,000 each in one year, from tariffs alone.

Action:

• Formation of “High Impact User” group, based in the ED, comprising:

o ED Consultant (medical lead)

o ED Matron

o GP

o Clinical Nurse Specialists in homeless health, mental health, drug services and alcohol services.

o Focussed input when required from

Epilepsy

Learning disability

Ambulance service

Probation services

Independent Domestic Violence Advisor

• Monthly MDT then individual approach from team members

• Identification of ten most frequent attenders for each month and proactively managed those cases by:

o Making individual Patient Support Plans

o Risk assessment

o Behavioural contracts

o Crisis planning for alternatives to ED

o Nomination for Golden Key scheme

o Referrals where appropriate e.g. medically unexplained symptoms clinics, psychotherapy,

Results after intervention:

• ED attendances were reduced in ALL patients managed.

• Super-user group - attendances and hospital admissions reduced by 80%

• ED and hospital admission tariffs reduced by 80%

• All primary mental health attendances reduced by 30% on average

• Patient feedback universally positive

• Staff feedback reported high levels of satisfaction with Support Plan use due to safer discharges, better informed decision making, and use of clear behavioural boundaries

• Some case examples of patients who were super-users NEVER coming back to ED after intervention (2 year follow up so far)

* Please list the most significant results

Improved value through:

• Reduction in ED attendances and admissions of up to 80%

• Savings from tariffs of up to 80%

• Improved patient experience:

o Consistent approach across all partner agencies

o Clear boundaries

o Supported rather than being “rejected” by ED

o Encouraged to take responsibility for health, not paternalistic

o Avoid repeat investigations and hospital admissions

• Improved staff experience:

o Clear plans for challenging patients

o Violence and aggression incidents managed safely/supportively with “red card system” and behavioural contracts

o Pro-active risk assessments for high risk patients

o Safe avoidance of repeat investigations and unnecessary admissions

* Describe how your project has spread to other teams, departments or organisations

• Successful business case resulted in commissioned service with funding for ED Consultant and nurse co-ordinator time for HIU team

• Regional network for HIU

• Awards won in 2017

o BMJ Award in Prevention Category

o Royal College Emergency Medicine (third place) in Patient Experience Category o Generated interest from several sites – now involved in supporting other sites with implementation

• Academic Health Science Network – online toolkit produced for other sites to use

• Video for NHS Improvement to use to promote good practice, telling the story from the patient’s perspective using some of our service users – in progress 

Key individuals

Rebecca Thorpe