Paul Miller
Director of Operations,
West Lincolnshire PCT
Tel: 01522 515362
Email: Paul.Miller@westlincs-pct.nhs.uk
Summary:
Many people go into hospital unnecessarily because there are few alternatives. Our objective is to reduce (unnecessary) emergency admissions to Lincoln County Hospital by 1,010 in 2005/06. Between July and November the PCT established a 24/7 community response service to provide services between ‘hospital and home’ for patients who have immediate health problems not requiring treatment in hospital. The community response service provides assessment, rehabilitation in 75 community beds and crisis support to 100 people each month. Emergency admissions have been reduced by 128 in August; 148 in September and 18 in October compared to the same months last year.
Abstract:
Our aim was to re-organise and expand existing community services to develop a 24/7 community response service (CRS) to provide alternatives to hospital admission. The CRS provides a range of services through a single point of access (SPA): a credible, highly professional and simple route into the CRS for GPs, health care professionals and social workers. The CRS provides the range of services as shown below:
Single Point of Access to: Assessment Service; Crisis intervention for up to 72 hours; Community Facilities; IV at home service (Dec 2005); Discharge Assessment Rehabilitation Team
The assessment service is provided by the PCT's intermediate care team and district nursing service with all referrals being responded to within two hours.
The assessment service is provided by the PCT's intermediate care team and district nursing service with all referrals being responded to within two hours. Crisis intervention support, for up to 100 patients per month, is available to the patients in their own home for up to 72 hours.
The community facilities comprise of 75 intermediate care beds located across the PCT in NHS facilities, social service’s homes and in the private sector. All the beds receive medical cover from GPs.
The service to provide ‘at home’ intravenous medication is due to start in December 2005.
The discharge assessment rehabilitation team (DART) works within A&E to divert from unnecessary admission those people who have completed their phase of treatment in A&E but who need some support in the community either at home or in a community facility.
All services are provided 24/7 with the PCT's primary care out of hours service providing them outside of normal working hours. We have expanded our intermediate care service staffing; increased our beds by 8 in the independent sector and by taken over the management of 20 acute beds; re-aligned our district nursing service to ensure a 2 hour response; set up a single point of access; created a crisis support service and developed our out of hours service so we can provide all services 24/7.
The services link directly to the national target to reduce emergency bed days; the local targets to reduce emergency admissions and length of stay and the need to reduce acute bed capacity to contribute to financial balance in the health community. In addition the services are entirely in keeping with Creating a Patient Led NHS – they are responsive, patient centred and high quality.
The PCT’s Director of Operations has championed the change internally and externally to build effective working relationships with consultants and hospital managers who are relying on the PCT to deliver alternatives to admission to enable service changes in the hospital. Examples of change techniques we used are: action planning; experiment and adaptation; partnership working at all levels; leadership at all levels; service development; force field analysis; clinical engagement.
This work has been commented upon and shaped by our PPI forum, GP forum, nurse forum and presented to the Lincolnshire Health Scrutiny Committee for their comments. Staff have shaped service developments through direct participation in the implementation team and via workshops held across the PCT.
Patient views and experiences of intermediate care services, DART and out of hours services gathered through surveys and case analysis have fed into our work to ensure an absolute focus on: delivering active support to patients and access to relevant health care at the right time – the consistently right response; promoting independent living; improving health and the quality of life; fostering self care and self management; improving the patient experience.
There are several examples of role development: intermediate care staff developing systems, procedures, protocols etc. for and operating the single point of access; development of intermediate care assistants to provide crisis support at home; out of hours staff taking on all CRS duties during all out of hours periods; forthcoming development of SPA staff to take calls on behalf of the emergency assessment unit; independent sector staff supported to deliver intermediate care; acute sector staff adapting to their ward moving to PCT management i.e. becoming a community resource.Performance is measured daily and monitored monthly when an analysis of emergency admissions is reported on to the emergency admissions avoidance committee. The critical figure is the number of emergency admissions, which is reported to the SHA. The data indicates a significant reduction in emergency admissions compared to the other Lincolnshire PCTs and a halt to the growth in emergency admissions. Work is underway to evaluate health outcomes for patients.
The deterioration of function often characteristic of a hospital stay is avoided and independence is more likely to be maintained, as are family ties, community support and social contacts. The service is highly professional with an emphasis on care being provided within two hours of referral, which brings help to the patient much quicker than waiting for a hospital admission. Individual care plans are agreed with the patients and their progress is recorded and reviewed with them. Patients give very positive feedback about the care they receive and the services we access for and with them beyond the CRS.
The service is entirely patient centred. Health needs are carefully and thoroughly assessed using the single assessment process, which is sensitive to and addresses diversity. The PCT staff have received diversity awareness training and the PCT has achieved IWL practice plus status.
This work has been presented to the Lincolnshire Health Scrutiny Committee, the Trent chief executives forum, posted on the PCT website and been submitted to the DoH as an example of good practice for inclusion in the forthcoming white paper on out of hospital care.
The CRS is a new patient pathway in its own right supported by protocols, criteria, quality standards, etc. Reducing emergency admissions for the first time in many years and achieving good health outcomes best demonstrates our energy, imagination and innovation. This is a truly ground breaking piece of work by a team which has met weekly for 12 months to design services and overcome all obstacles to their successful implementation. The determination, absolute focus and pace at which the implementation team has worked and continues to work is outstanding.
