1. Pro-active Care The virtual ward
Dr Phil Ridsdill Smith
Julia Davis

2. What is it? 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).

3. Where did we start from 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.

4. National Data - 999 calls for falls
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
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 once
Snooks HA, Quality & Safety in Health Care 2006;15(6):390-2

5. Gold Standard Framework (GSF)
Graphs to show typical end of life trajectories by disease type.

6. The advantage of PAC data
Visit
PAC
PRT SLAM
Docobo
GP Visit
GP Visit
999
Admission
Intermediate care
GP Visit
Admission
Social services
999
999
OOH GP
The timeliness of the data is key to managing transitions of care and frailty crises effectively. The data used in Pro Active care is current which means that within Pro Active Care there is the potential to manage all interventions to the right of the red line and to add value to patient care with each subsequent intervention rather than incurring costs without benefit.
Predictive Risk Tools are not as sensitive as Pro Active Care data. The data sources that they rely on are too old to assist in the immediate management of a problem only flagging patients up after the event. There is a risk that interventions based on the Predictive data will be arbitrary and add additional cost to the pathway if they happen once the patients condition has stabilised.
On 17th November the Nuffield Trust commented that the evidence for PRTs as hospital-avoidance interventions is patchy – we think this slide demonstrates why.
Clinical hunch

7. Proactive Care –Identifying Suitable Patients and the role of the Tracker
Out of Hours Reports
checked daily, potential patient records reviewed and GP or Community Matron consulted if necessary.
Emergency Admission Lists
received 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.
999 call data – would be useful
Urgent Care Dashboard – last CCG to have it but gives daily updates from RSCH data of A+E and unscheduled admissions.

8. Screen of patients

9. Weekly meeting Community matron and Dr
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 plan
which is then shared with OOH and IBIS

10. Summary sheet

11. Monthly meeting Format Consists of Learning format
Projector and screen
Review each set of notes
Review care plan
Enter data as we go
Learning format
Consists of
All doctors
Community Matron
District Nurses
Social Services
Mental Health
Paramedics
Pharmacist

12. Our progress so far 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

13. Issues arising most regularly
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)

14. JRD 91 year old lady – retired dog breeder
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”

15. JRD
Readmitted 22/3/ 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 discharge
neighbour re-laid floor
Reablement team went in
Medicines sorted
Mental Health Team reviewing
Co-ordination of various teams for input
Cardiology, PNs, DNs, Physio, CoE, Mental Health and Neighbours
No further readmissions, 2 further out of hours in 9 months

16. GD – 49 years old alcoholism
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

17. Risk Profiling DES 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”