Preventing hospital admissions through anticipatory care planning and self-management education Advanced Nurse Practitioner Example

Initial referral Patient A was referred to the ANP to discuss developing an Anticipatory Care Plan (ACP) with the aim of preventing hospital admissions. High SPARRA score. Frequent hospital admissions with exacerbations of COPD. Smoker. Main carer husband. Patient A is unable to wash/dress, cook or prepare snacks independently. Requires supervision to mobilise. Husband has own health problems though is independent.

ANP Input Extensive education on COPD inclusive of Recognition of early signs and symptoms of exacerbations, literature provided Smoking cessation advice and support Review of inhaler technique Rehab team input – physio (chest and physical asx), dietician assessment Carer assessment ACP developed and implemented inclusive of husbands needs COPD self-management plan implemented – traffic light system, antibiotics and steroids at home Crisis management – support, as required, during an exacerbation, carer support, liaison with other services if required. Continuous patient and carer support – home visits, telephone advice, liaison with GP practice

Crisis plan Patient AHusband Patient A identifies exacerbation, follows self-management plan and commences antibiotics/steroids. Patient A/husband calls ANP to alert her to the exacerbation. The ANP will then do a home visit and assess the situation. Liaison with GP and other services as required. Assessment and support at home, as required, by ANP thereafter. Carer support. Update ACP if required. If unwell he calls GP/ANP. Assessed by GP/ANP. If hospital admission required, ANP would arrange full package of home care for Patient A otherwise she would have to be admitted hospital/emergency respite. Telephone calls/home visits to support Patient A whilst husband in hospital. Update ACP if required.

Patient A now Patient A was supported to stop smoking She now has an oxygen concentrator at home as well as a nebuliser Her husband is well supported With ANP support, Patient A is now able to be managed at home during most exacerbations. Unfortunately couldn’t avoid an admission this week, too unwell, complicated exacerbation However….

…Patient A had been at home for 48 days. 2 hospital admissions have been avoided in 2014 through use of the COPD self- management plan, GP support and intensive ANP input/support Last year, Patient A had 7 hospital admissions, average admission was 2 weeks (91 bed days 2013) approximately every 6 weeks. (Some of these admissions were unavoidable.)

Moving forward Continue to prevent Patient A being admitted to hospital where possible and safe Continuous support to Patient A and her husband Regular liaison with GP Update ACP when/where required