Older persons assesment team telephone follow up project

Category:          Addressing an overall National Service Framework

Name:               Dr Lizzie Witherington

Job Title:           Clinical Assistant, Healthcare of The Elderly

Organisation:    Nottingham City Hospital NHS Trust

Email:                ewitheri@ncht.trent.nhs.uk

Telephone:        0115 9691169 x49958

Key team:          Joyce Harness (Ti2), Laura Nicholson (Senior OT)

Title:                 Older person's assessment team (OPAT) telephone follow-up project

As part of the National Service Framework for Older People, Standard 3:Intermediate Care, at Nottingham City Hospital, Morton Ward was set up in July 2001 to provide rapid access to rehabilitation and multidisciplinary discharge planning, with ongoing Consultant-led medical care. Patients were referred from acute wards for their potential ability to benefit from effective rehabilitation services to enable early discharge and to prevent premature or unnecessary admission to long-term care.

Despite this theoretical selection of ‘fitter’ patients, the readmission rate for Morton Ward initially was similar to that for all patients aged 75 and over.

An audit of Morton Ward readmissions found that 50% of patients returned within 7 days, and 65% returned by 14 days.

By implementing telephone follow-up, we hoped to identify problems arising soon after discharge and either to advise patients and carers directly, or to signpost them to the appropriate community agency to prevent the problem becoming a crisis.

The readmission audit also found that over-optimism of ability to manage was a factor in readmission, including cases where the ‘carer’ is a frail elderly spouse. We hoped that the telephone call would succeed in offering services, e.g. Day Hospital, which had previously been declined when patients and/or carers overestimated their functional ability.

We expected improvements in quality of care and patient and carer satisfaction through greater involvement in their care. Those who were reluctant to ‘bother’ their GP could be advised which problems needed urgent attention, and where and how to seek help. Also, by enquiring about use of medication for example, the risk of adverse events and errors from discharge documentation and repeat prescriptions would be reduced.

GP's would benefit: a local GP recently remarked: ‘If only we had a way of knowing which patients need us most after discharge.’

We expected further service improvements; both for the team, by identifying common problems which need more attention before discharge, and, through feedback to the wards, to improve discharge planning.

• The hospital overall would benefit if the readmission rate could be reduced.
• The OPAT team began telephoning patients whom they had seen during admission, and whose discharge they had helped to plan. Structured calls were initially made at 2-4 days after discharge and then at 2 weeks.

The project was led by Joyce Harness and Laura Nicholson with help from Emma Fishpool (Senior Physiotherapist).  Lizzie Witherington collated the data.

There was an immediate, positive response from patients and carers, who appreciated both the opportunity to discuss their concerns, and advice about how and when to contact appropriate community agencies.

Of 326 patients were called, 42% had problems within 2-4 days of discharge and 51% had problems within 2 weeks, all of which were addressed by the team.

Other achievements became apparent from the data review, e.g. the percentage of patients with problems with medication at 2 weeks (26%) was much lower than that quoted in the literature (57%). 4% accepted Day Hospital referral as a result of the call.

• Time: such was the appreciation of the benefits of the project that the team used their breaks to make calls.
• Knowing which community agency to contact: the team has built up a directory.
• Speed of response: sometimes the team went out themselves because community agencies could not provide a fast enough response.
• Responsibility: calls were made until a named person took over responsibility.
• Staff morale was boosted by the overwhelmingly positive response from patients and carers.
• Links have been made with PCTs providing post-discharge follow-up services, to facilitate quicker access for patients needing urgent assistance.
• These links also enable the team to draw attention to gaps in service provision e.g. services arranged but not delivered.
• We are expanding our links with the PCTs, and the project has been redesigned as a result of the initial data review to focus on frequently occurring problems.

Following presentation to the HCE Directorate, with support from the Pharmacy Department, the project has been adapted for SHO telephone follow-up, focusing on medication issues.

The initial data have informed the need for urgent improvement in immediate discharge communications.