1. Reducing Emergency Admissions An Anticipatory care approach to reducing emergency admissions Miss Kathleen McGuire Long Term Conditions and Community Ward Manager

2. Why? Burden of ill health locally- A&A High prevalence of disease
Targeted risk prediction
Proactive multidisciplinary care can reduce emergency admission (LTCC 2009)
Joint reviews of care (nursing, GP, secondary care & social work)
Co-ordination of care
Patient pathways with referrals between services
Prepared pro-active teams
Anticipatory Care Plan

3. Anticipatory Care Approach
Population pathway based approach to improving health and care
Self Management
Proactive co-ordination of care
Integration and multi disciplinary working
Accessible shared single patient record
Prevent Emergency Admissions

4. Improvement; health education
RISK PROFILE IN AYRSHIRE & ARRAN
Acute sector
Individuals with
complex needs:
case management
(3-5%)
11,000-18,000 PATIENTS
High risk:
Disease
management
(15-20%)
,000 PATIENTS
emergency
admissions
Lower risk:
supported self-care
(70-80%)
,000 people
Interventions
Outcomes
Public health; health
Improvement; health education

5. Coordinators of care - Anticipatory Care Plans (early stages)
Complex Needs/Co-ordination of care 11,000-18,000 patients ( some systems & processes)
Coordinators of care - Anticipatory Care Plans (early stages)
Community nursing teams and modernisation
Reshaping Care & Change Fund
Integrated Care & Enablement Services
Community Wards
Nursing Homes ACP
Palliative Care Directed Enhanced Services
QOF/Key Information Summary (KIS)
Integrated Health and Social Care
HUBs/SPOC

6. High Risk Disease Management 56,000- 75,000 patients
Co-ordinators of Care/ Case Managers
Anticipatory Care Plans
Specialist Nurses
Community Nurses
Community Wards
General Practice &Practice Nurses/CDM
QOF
Anticipatory Care Plan/SPARRA
Managed Clinical Network/Acute Hospitals Interface Initiatives and Services
Hospital consultants in community
Telehealthcare
Social and local authority services

7. Lower Risk/Supported Self care
Self management
Co-production
Education & information
General Practice
Telehealthcare
Peer support
Local Authority services
Voluntary services
Etc

8. Girvan Community Hospital
Telehealthcare
An overview of the use of ACPs in Telehealthcare
Dr Kenneth Brooksbank GP
Girvan Community Hospital

9. What is an ACP?
Allows patient to be actively involved in decision making, what treatments are acceptable and where they wish to be treated. This has particular importance as advance care planning as patient’s approach end of life.
Allows supported self management, has the potential to address patient’s concerns and goals and enhance their understanding of their long term conditions.
ACP’s have also been shown to reduce hospital admissions.

10. Currently 24 patients in South Ayrshire who self care, monitor their own vital signs and symptoms on a daily basis before sending the results to the Community Nursing Team, all these patients have an ACP in place.

11. Telehealth Self-Management Pathway
Complicated slide. 2 aspects here of self management: all patients had medicines in reserve, some elected to undertake cocreating health self management programme.

12. Example 1
67 year old lady
Very severe COPD, on LTOT 4 years, housebound.
3 admissions to hospital prior to commencing telehealth 2 years ago.
Since starting telehealth, still has exacerbations but no hospital admissions.
Feels supported and confident in managing exacerbations at home and using opiates to palliate breathlessness.
Has ACP but still a challenge in introducing end of life issues.

13. Example 2 72 year old man with moderate to severe COPD
Developed bronchial carcinoma while on telehealth
Wished to continue telehealth monitoring
Home monitoring of O2 sats picked up hypoxia caused by radiation induced fibrosis.
Allowed early use and benefit from steroids and oxygen, enabling patient and wife to be supported at home, preventing hospital admission.
Increased involvement of DN’s and GP’s
Patient died peacefully at home.

14. Patient Feedback
‘I think it is brilliant, I have learned how to recognise my own readings and if I think I have been a bit too active before I do them I don’t send them, relax and do them again before sending them’. Patient
‘I think it is really excellent, I haven’t seen my GP since I started doing this but I know I am being monitored every day so I don’t have to worry’. Patient

15. Clinician Feedback
‘Since the first patients have had the equipment in their homes I have had less need to see them in surgery. Patients seem to be in more control of their condition’. Clinician
‘Because we check the alerts daily, we have managed to contact a number of patients showing early signs of exacerbation of COPD and advised them to start their medicines in reserve, possibly averting a hospital emergency admission’. Clinician

16. Dr Conrad Harvey, North Community Ward GP Ayrshire Central Hospital

17. An overview of the use of ACPs in The Community Wards

18. The essence of what the Community Ward does....
We undertake a case problem-solving analysis to identify each individual patient’s reason for admission from GP & hospital notes (and communication with their clinicians if necessary), and meeting the patient +/- family/main carers;

19. The essence of what the Community Ward does....
2. We then identify a tailored solution that is likely to work for them eg in terms of :
change in medication;
self-management training;
instant access to rescue therapy in their own home 24/7;
psychological management;
enhanced monitoring eg in person or telecare.

20. The essence of what the Community Ward does....
3. We then put our ACP or enhanced/ integrated clinical management plan in place, if it is accepted, and record it within EMIS; KIS (with the patient’s consent) and within our red folder in the patient’s home/nursing home;

21. The essence of what the Community Ward does....
4. We adapt the plan over time so that it is responsive to the patient’s needs (eg if there is a changing bacterial species causing infection needing alternative rescue empirical antibiotics);

22. The essence of what the Community Ward does....
5. We offer a medical first–responder service Mon to Fri (normal GP working hours) to ensure continuity of support and that our plan is adhered to.