APPENDIX 3
EXTRACTS FROM INTERNAL EVALUATION OF AN ADMISSION
AVOIDANCE SERVICE
The Redbridge Rapid Response Service was provided
to meet the needs of elderly, frail patients in the community.
The service was aimed at reducing length of admission and duration
of hospital stay for elderly patients in the Redbridge area.
The services commissioned were: Rapid response
assessment in the community that could be accessed by GPs; Admission
avoidance that supports individuals to go home from hospital,
Accident & Emergency or Medical Assessment Unit; Specialist
services such as Peripherally Inserted Central Catheter line placement;
Intravenous antibiotic administration; Emergency urinary catheter
management
It was anticipated that the service be provided
for two weeks, thus allowing time for the statutory services ie
Social Services to assess and establish appropriate ongoing care.
The service was led by experienced senior/specialist nurses and
four carers. They undertook assessment visits within four hours
to arrange and manage care packages.
The outcomes sought from the service were to:
— Reduce pressure in King George's
beds over winter 2000-2001 thus facilitating efficient bed management
— Avoid inappropriate admissions/ensure
maximum benefit was obtained from the new MAU
A total of 70 patients were referred to the
service, which ran from 29 December 2000 to 24 April 2001 as a
time limited "Winter pressures" arrangement.
Nurse Specialist Assessment
The assessment carried out not only builds on
current "best practice" but also helped to develop it.
Home Care (MDS-HC) assessment package in conjunction with Kent
University. MDS-HC delivers a comprehensive and consistent assessment,
founded on an opinions-based methodology, used in 19 other countries
world-wide. This results in patients being assessed with an objective
instrument, producing a tailored care plan thus providing a far
more effective measurement of the quality and outcomes of care.
GPs and patients identified the need to support
frail elderly whose vulnerability often resulted in hospital admission,
when increased support in the community could have avoided this.
Three target groups of individuals were identified as potentially
benefiting from the RRS.
1. The frail, elderly individual with a
minor health problem, who subsequently is unable to carry out
the activities of daily living.
2. Individuals whose fragility resulted
in hospital admission often with slow recovery and potential readmission.
3. Individuals at risk of losing their independence,
with detrimental consequences, if remaining in hospital longer
than necessary. The RRS was perceived as being able to support
timely discharge or to provide treatment and monitoring at home
where appropriate.
The "target groups", identified from
the analysis, presented valid challenges to current service provision,
which generally focuses in one aspect of clinical need. GPs also
reported that delays inherent in the referral and assessment process
further exacerbated the situation for very vulnerable older people.
CLINICAL OUTCOMES
A total of 70 patients were referred to RRS.
The average age of the patients was 79.7 years (range 41-94 years)
with 591 days spent in total delivering care, averaging at 8.4
days per patients. The predominant referrers were GPs (n=26),
closely followed by the Social Workers (n=23, 43 per cent were
Hospital-based Social Workers). Referrals from the hospital; A&E
and the MAU were lower (Figure 4).
The Nurse Specialist assessed every patient
within four hours of being referred to the service. A care package
was devised and reviewed at regular intervals by the Nurse Specialist.
The majority of care was delivered by care workers, More specialised
nursing, such as administration of intravenous and subcutaneous
medication, accounted for just nine per cent and one per cent
of care packages respectively.
The outcomes of the care packages, (Figure 6)
demonstrated that just over 31 per cent of the patients (n=22)
were referred onto Social Services. In 10 cases, the RRS extended
their package beyond the agreed two weeks whilst Social Services
were arranged. The additional time ranged from three days to three
weeks, with a total of 71 additional days required (12 per cent
of the total time).
In just under a quarter of the cases (24 per
cent) the care package was successfully completed ie no further
intervention or ongoing referral was necessary for this clinical
episode. In 21 per cent of cases (n=15) hospital readmission was
required. No service was required by 14 per cent of the patients,
as the RRS was either refused, patients were out of the area or
not suitable for RRS. Two patients were referred back to the District
Nurses and two were admitted to Nursing Homes for ongoing care.
The Redbridge RRS demonstrated that the cross-organisational
boundary between the NHS and the independent sector has been bridged
through collaboration. The Nurse Specialists reported that they
had initial resistance from the local District Nurses. XXX were
perceived as undermining their role, perhaps by demonstrating
that as Nurse Specialists they had more time to deliver care.
District Nurse visits were very short, providing little opportunity
to assess the patient thoroughly. Some care overlapped, such in
continence care and pressure sore management, further facilitating
a greater understanding of the Nurse Specialist's role.
However as the Nurse Specialists were usually
only delivering specialist care, such as IV therapy administration,
there was not specific role conflict, since few of the local community
staff was IV trained. As the RRS progressed, some District Nurses
were more favourable to the service and began referring patients
and actively communicating with the Nurse Specialists. This collaborative
approach is part of the specialist nurses development in sharing
skills and expertise with general nurses with skill transfer is
essential in implementing change. Although the RRS was not operational
to demonstrate long-term changes, similar existing service delivery
by the Nurse Specialists has demonstrated this collaborative relationship.
Additionally the Nurse Specialists reported
surprise at the level of care required by the majority of the
patients referred to the RRS. As documented earlier, most patients
required simple care, usually related to personal hygiene and
domestic tasks, carried very effectively by the carers, as demonstrated
in both high levels of patient satisfaction and hospital admission
avoidance.
Experienced Nurse Specialists ensured an accurate
and individualised but holistic assessment took place for each
patient. The subsequent care package identified and met patient's
needs rapidly and efficiently. Strong links with the GPs were
evident, strengthened through regular and clear communication.
GP satisfaction supported this feedback. Unexpected links with
the local continence service were developed and worked well throughout
the service. Other services not anticipated were Deep Vein Thrombosis
(DVT) management for one patient and wound care. No palliative
care patients were referred to the RRS.
Strong links were developed with local social
services. There was an increasing referral rate from both community
and hospital social workers. The patients, whose problems were
predominantly social/rehab in origin, anecdotally accounting for
60 per cent of all patients, reflected this. The Nurse Specialists
demonstrated an example of collaborative and flexible practice,
as a one third of referrals were referred onto Social Services.
In 10 cases the care packages were extended, by often considerable
lengths of time, up to three weeks in one case, whilst social
services were able to instigate ongoing care. This delay was due
to cases going before the Board for approval and discussion, rather
than care being decided.
Perhaps the most important impact of the service
was the high level of patient satisfaction. Respondents reported
very positively the value of receiving care in the home, which
carried the most responses. Care specifically tailored to their
needs was largely viewed as "extremely important", as
was the value of having competent and well-trained nurses/carers.
Punctuality was either "extremely important" or "important".
Overall satisfaction was extremely high with 93 per cent of respondents
either "very satisfied" or "satisfied".
The RRS appear to have successfully, albeit
temporarily bridged the gap that existed in the secondary-primary
care interface in Redbridge. Three target groups of patients were
identified as being most in need of a rapid response service.
Most care delivered by carers, ranging from low to high input,
resulting in a proportion of the patients avoiding or delaying
hospital admission.
Both patient and GP satisfaction was high, suggesting
that the services met the anticipated needs of both the local
client groups and existing health care providers. The RRS also
met several government initiatives, NSF for Older People, NHS
Plan and Shaping the Future.
Several key nursing texts identified various
founding principles underpinning such a service, focusing on collaborative
practice, thorough nursing assessment, clinical standards, professional
accountability and sharing good practice. In addition the RRS
demonstrated an excellent example of skill mix, utilising the
most appropriate health care professional to deliver care.
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