Dr Phil Ridsdill SmithJulia Davis

Good care for the most needy patients It involves:

◦ Finding high risk patients of any age, using timely data.

◦ Identifying the healthcare professionals involved.◦ Creating an MDT care plan.◦ Working as a team to minimise risks◦ Sharing the information we have with out of hours

and the ambulance service (GP practices cover, on average 50 hours of a 168 hour week).

Disjointed team◦ GPs◦ Community Matron and DNs◦ Social services (similar patients - different interventions)◦ Mental Health◦ SECAmb◦ Hospital

Different teams taking an independent approach to treating the same patient.

34% of patients with falls not conveyed after 999 call Median 34 minutes spent at scene

Marks PJ. Emergency Medical Journal 2002;19:449-52

Non-conveyed patients more likely to be older housebound poorer cognition Close JC. Age Ageing 2002;31:488-9

8% of all calls to London Ambulance Service (n=60,064) due to a fall in 2003-4

25% of all calls aged >65 years due to a fall n = 534 / 2151

49% made contact with medical services in next 2 weeks

47% called 999 again at least onceSnooks HA, Quality & Safety in Health Care 2006;15(6):390-2

Gold Standard Framework (GSF)

Graphs to show typical end of life trajectories by disease type.

VisitGP

Visit Admission

OOH GP

Clinical hunch

PAC

999 Intermediate care

GP Visit

GP Visit

Admission999999

PRT SLAM

Social services

Docobo

Out of Hours Reports checked daily, potential patient records reviewed and GP or Community Matron consulted if necessary.

Emergency Admission Listsreceived daily, all patient records are reviewed. Potential patients are added to the Recent Admissions List (see below)

Recent Admissions List (compiled from the above) checked weekly for discharge information.

PANDA list (patients who have been in hospital >9 days) checked weekly and any patients discharged since the previous week are investigated.

Clinical hunch – all those who attend the MDT meetings and local Care Agencies have all been invited to add patients to the list.

Review of those attending the GP surgery

Combined Predictive Tool (Docobo based on Kings Fund PARR++ tool)used occasionally but patients identified via this method have invariable already been picked up.

Patients causing concern are added to the Proactive Care appointment screen by the Tracker to be reviewed by the GP and CM at the next weekly meeting-

◦ Anyone can add a patient to this screen and◦ Anyone can see whether a patient is under review by the Proactive Care or part

of the Proactive Care Caseload.

– Review each patient on the list and those identified by the Tracker

– Verbal update on progress, home situation, other agencies involved

– Community Matron role• Your eyes in the community• Communication with the hospital to ensure smooth flow of information

to and fro• Liaison with social services, housing, charities etc• Actions and reviews.

– My role• Notes summary – including soft data• Review patient notes, letters and recent admissions• Review of medicines – reconciliation, necessity• Co-ordinating role within practice for GPs, DNs , CM and the Tracker.• Admin support etc

– Agree care planwhich is then shared with OOH and IBIS

Consists of◦ All doctors◦ Community Matron◦ District Nurses◦ Social Services◦ Mental Health◦ Paramedics◦ Pharmacist

Format◦ Projector and screen◦ Review each set of

notes◦ Review care plan◦ Enter data as we go

Learning format

18 months of activity 127 patients have been in our virtual ward 20 active at any one time 10 crises per week 3 admissions per week

Communication with other agencies Medication errors, compliance and

stockpiling Social Issues Mental health issues (alcohol and dementia) Results and actions following discharge Sharing information (IT etc)

Multiple problems◦ Heart failure, heart block, COPD◦ Falls, Hip fracture, osteoporosis◦ PMH temporal arthritis and retinal artery occlusion◦ Lives alone, cluttered house, refuses all help

Admissions◦ 24/12/11 - #NoF and DHS in RSCH◦ 11/1/12 to 13/2/12 to Milford Hospital for rehab – independent with ZF

by discharge

Onto PAC 20/3/12 “very high risk of readmission”

Readmitted 22/3/12 ... But straight into Milford Hospital to get further rehabilitation:◦ Non-compliance had led to further oedema, ulceration and cellulitis◦ Iv abs and better fluid balance required ◦ Discharged 18/4 – independent with ZF

Readmitted 7/5/12 to 29/5/12 with a pleural effusion secondary to pneumonia – iv abs and chest drain

Following dischargeneighbour re-laid floorReablement team went inMedicines sortedMental Health Team reviewing

Co-ordination of various teams for inputCardiology, PNs, DNs, Physio, CoE, Mental Health and Neighbours

No further readmissions, 2 further out of hours in 9 months

Joined list 4/11/12 PMH

◦ Alcoholism◦ Diabetes

Attention over 12 months◦ 14 GP visits◦ 5 acute admissions◦ 6 A+E attendances◦ 4 ambulance call outs recorded

Agencies◦ Carers, GP, DNs, Diabeties Nurse, ACORN, and Mental Health

Intervention◦ Respite admission to Crest Lodge – more structured environment◦ Mental Health Assessment - Chronic Alcohol Dependence – lacks

capacity◦ Deprivation of Liberty Safeguarding

NHS Commissioning Board set CCG to define locally 74p per patient Your are required to

◦ “undertake risk profiling and stratification”◦ “work within a MDT to identify those who are

seriously ill or at risk of hospital admission”◦ “co-ordinate with other health professionals”