Frequent Attender Nurse and Pilot Study Jim Welch, RMN. Mental Health Liaison Manager, 2gether.

Background: There is little guidance on the management of this patient group and little published. “The College of Emergency Medicine, Best Practice Guideline” (2014) Literature tells us that “Frequent users of other services GP and Ambulance, vulnerable are at high risk of morbidity. There is excessive use of services whilst in crisis however this frequency will drop” Bespoke plans DO NOT reduce attendances to the department But they ensure “safer care” They give a safer analgesia strategy (helps with drug seeking behaviours), patient involvement and collaboration formulating the plans also helps with adherence.

So where to start cont… The document outlines what and how the plans should be formulated by MDT. Assessment should be conducted by a senior clinician and provide clear guidance on: Who should see the person. Reducing any unnecessary tests. Ensuring consistency of care. Summarising and defining historical and current risks. Supporting the person whilst in A&E including any special measures or contacts. Recognising the challenges with engagement.

Identifying the patients Criteria is 10 x in 12 months or 5 x in 3 months Use of a “Tracker” (Spreadsheet, Data from Hospitals IT) amalgamated with information from Rio. Identify “Mental Health” Frequent Attenders, on a monthly basis through data and also “word of mouth” Assess Patients within the hospital setting, reaching a decision that promotes a safe and supportive discharge. Whilst acknowledging lifestyle choices and impulsive behaviours that may lead to significant adverse outcomes.

Frequent Attender Manager Role: Patients within the “Frequent Attender Programme” are high intensity/complex individuals with multiple issues and needs, Follow up appointments with patients and where possible Lead Professionals/Care Co-ordinators. Outreach work - visiting patients at their homes, using an holistic approach to aid engagement with services that meet their needs, Evaluating patient experiences and finding alternative solution’s,

Frequent Attender Manager Role: Close working with unscheduled care (A&E, ACU) Co-working with 2Gether services (MHLT, Recovery, AOT). Close working relations with SWAST - Frequent Attender Paramedic. Contacts within Turning Point – to be further developed. Close working relationships with Police, Liaising with GPs, sharing information, formulating plans, Interface with the Pain Management Team, using their specialist knowledge and advice within the plans i.e. Patients with drug seeking behaviour, Plans are developed with the patient outside of the “crisis”

Frequent Attender Manager Role: Co-ordinating and participating in Professionals meetings. Co-writing care plans with clear concise boundaries which manage patients whilst in the Emergency Department or hospital setting. Clear signposting for discharge (avoids delays whilst managing risk and supporting the patient). Provide continuity with “Frequent Attender Patients” whilst in the department and afterwards. Monitoring of contact and reason for contact. Improving staff awarenessand morale.

Case Vignette: Patient ZW, Drug seeking behaviour at A&E and SWAST, 2014 - 49 x attendances, Admitted 29x 2015 - 51 x attendances, 18x admitted, June – plan developed 1 x admission to date. Plan highlights professionals involved and advice for pain relief (given from Pain Management Team) it has reduced regular Opiates, given by Ambulance service, A&E and on the wards and alternatives are reinforced.

Future Developments: It would appear that this role Does NOT reduce attendances. However it manages the patient in a consistent way. It would appear that it reduces the need for, or length of, admission by providing a clear discharge plan. Develop Early Intervention: diverting/signposting to services outside of A&E breaking cycle of attendance. Improve IT systems to capture Mental Health related presentations with greater reliability (in progress).

Future Developments: Clear referral pathway, at present ad hoc from clinicians. Continue to build positive relationships between services, providing a positive interface. Closer working relations with 111, Closer working relations with Turning point, Co work with GHNHSFT frequent attender manager (newly appointed).