* Please describe the challenges or problems your solution set out to solve.
Work commenced with the nursing home sector three years ago, at a time when there was an increasing suspension of admissions, due to poor quality and patient safety issues; these reduced market capacity and choice for people created financial uncertainty and led to delayed transfers of care from acute services to the nursing home sector.
Following a study to explore historical data to identify factors that led to emergency department attendance to the hospital, it was noted that 90% of residents were admitted to the hospital by West Midlands Ambulance Service from 999 calls made by the nursing homes and accounted for a total of 3,666 bed- days. 89.8% of hospital admissions were attributed to a diagnosis of chest infection, fall, urinary tract infection, constipation and end of life care.
* Please describe the actions you took to achieve your result.
The model was co-designed by; the nursing home managers, Walsall CCG quality & safety team, West Midlands Ambulance Service, General Practitioners, Walsall Healthcare NHS Trust, residents and their families. The business case for which was predicated on reducing the number of 999 calls made from nursing homes to West Midlands Ambulance Service, reducing the proportion of residents conveyed to hospital and to increase confidence, capability and capacity within the independent nursing home sector.
The overall aims of the model were:
Enhance Primary Care support - by aligning a GP practice team to each nursing home.
Wrap community services around the nursing homes - commissioning a dedicated case management service and access to Rapid Response Team.
Increase confidence, capability and sustainability in the independent sector - commissioning training, partnership working between primary and acute services.
High-quality end of life care - wrapping palliative care services around the nursing homes.
Building leadership skills - commissioning leadership training.
We recruited to 1wte Band 8a Advanced Nurse Practitioner and 1wte Band 7 Nursing Home Case Manager. Their role is to: Identify and undertake frailty assessments. Develop written management plans including advanced care planning. Support with co-ordinating specialist services in the community. Optimise/rationalise medication. Provide training to care home staff.
Standardised protocols for managing chest infections, urinary tract infections, end of life care, constipation and hypoglycaemia were developed, along with care pathways guiding the care of the frail older person.
In addition, the GP practice teams were commissioned to undertake weekly ward rounds with residents, their families, the care home staff, case managers and the practice pharmacist.
A virtual was developed to monitor residents receiving sub-acute in the community and residents were fast-tracked through the emergency department between the hours of 09:00-20:00, seven days a week. The model cost approximately £380,000 per year.
* Please list the most significant results
The number of 999 calls made to West Midlands Ambulance Service from nursing homes reduced by 91%. The proportion of residents conveyed reduced by 95%. On average 5% of nursing home residents are admitted into the acute sector per month. Between January 2017 to November 2017 there were 960 avoidable hospital admissions with a cost saving of £1,419,840.00 (base on the DoH costing 2014 data).
We compared the proportion of 999 calls made to West Midlands Ambulance Service from the residential sector (control group) that doesn’t have an enhanced healthcare model commissioned with the nursing home (Intervention group) sector. From Feb 2017- October 2017, there were 1008 calls from residential homes made to West Midlands Ambulance Service and 673 residents conveyed to the acute hospital. From nursing homes, there were 423 999 calls made to West Midlands Ambulance Service and 314 residents conveyed to hospital.
* Describe how your project has spread to other teams, departments or organisations
Walsall CCG and Walsall Healthcare NHS Trust worked in partnership with the neighbouring CCG’s including; the Royal Wolverhampton NHS Trust, Telford & Wrekin CCG and Solihull CCG, to co-design an enhanced healthcare models for care homes and transform healthcare services to meet the future needs of older people with complex long-term conditions residing in care homes.
Further work is on-going between Walsall Healthcare NHS Trust, the Royal Wolverhampton Hospital and West Midlands Ambulance Service to embed frailty screening, promote the admission avoidance care pathways and enhance skills within the nursing home teams.
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