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

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).

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.

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 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 once Snooks 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.

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

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.

Screen of patients

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

Summary sheet

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

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

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)

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”

JRD 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 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

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

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”