6 Essential Actions to Improving Unscheduled Care

Case Study Template - to be submitted first Monday of each month

Date 2nd May 2016 Site NHS Borders Contact Details Liz Duffell Title Development of an AHP led Rapid Assessment & Discharge Team 6EA EA6 Ensuring Patients are cared for in their own homes

Describe the project in 250 wordsLUCAP funding was sourced x 1 year to pilot using AHP’s (Allied Health Professionals) as a designated resource at ‘Front Door’ services at BGH. This commenced in March 2015 through to March 2016.

Prior to the pilot, AHP’s responded on an “as required” basis with various Physiotherapists and Occupational Therapists holding the bleep. These therapists were pulled from busy ward workloads and did not have capacity to provide a full functional assessment of the patient or to support the A & E / MAU teams with their overall decision making around whether to discharge or admit. The response times were particularly stretched with an average Length of Stay on MAU of > 2 days

Permanent funding is being considered to support this service as an integrated part of the General Medical re-design[Description of anticipated benefit]

EA1 / 2 - Prevent inappropriate admission to downstream wards EA 1 / 2 - Facilitate early discharge from MAU EA 6 - Provide a model for provision of same day assessment by AHP EA 6 - Improve access to AHP assessment for all medical patients by

providing a designated front door AHP team EA3 – RAD are an integral part of the Criteria Led Discharge model on

MAU EA1/6 - Earlier identification of appropriate pathways and / or rehabilitation

needs at the point of entry to BGH that would then inform the patient’s destination from the MAU.

EA5 - Support a shift in culture within AHP services to provide an extended service Mon – Friday and exploring 7 day working models

EA6 -Develop & improve pathways and links to community based services for support after ‘turnaround’ or discharge

EA6 - A timely AHP assessment to ensure that the patient receives the optimal outcome for their journey on arrival at BGH with an improved response time for completion of AHP assessments

EA2 - Offering a cross competency AHP assessment that reduces duplication for the patient and promotes patient flow realignment at the front door

EA 2 / 6 - Increase overall confidence to ‘turnaround’ a patient at the front door by utilising the AHP’s assessment of a person’s function /mobility to evidence a safe discharge. Next day telephone follow up to ensure that the patient feels supported to remain in their own home. EA1 / 3 - Utilising the AHP’s to improve patient flow with demonstrable

benefits to bed occupancy levels, early discharges, inappropriate ‘down

6 Essential Actions to Improving Unscheduled Care

streaming or admission’ of patients.

Improvement & Engagement approaches used] Methodology:We have used the PDSA approach throughout, from scoping the initial service constraints, prior to the pilot and all on-going development and operating procedures as we have progressed.Various PDSAs in the early months demonstrated that when involved we could affect a more timely discharge and influence patient flow. We also completed a large Test of Change week in late June across both ED and MAU to reinforce the approach of the team

Training: Either professional within the team underwent training to a cross competency AHP framework developed by the Unscheduled Care Services in Fife. The team also had clinical training in the A & E department to allow for expanded roles such as basic urine tests to identify infections; Active Stands and BP monitoring; monitoring of certain observations including Blood pressure and Oxygen saturations levels during activity. [Outcomes and evidence of impact of improvement on 6EAs, overall 4 hour performance or specific flow group(s)]

It has been challenging to demonstrate impact from AHP clinicians working in fast paced unpredictable areas where many factors affect flow, however the activity levels are beginning to demonstrate the impact that the team is making across both departments. The DoCA data supports the fact that having AHP’s at the Front door allows for improved timescales for assessment and intervention by AHP’s on the general medical wards.

Please see appendices

1. RAD Team activity by month2. RAD activity resulting in same day discharges 3. Age profile of patients seen 4. Source of referrals 5. Doca data around waiting for AHP assessment across Medical Wards 6. Prioritisation of RAD workload – future considerations

[Key lessons learned]

Preparation time prior to the actual clinical launch would have improved the activity levels from the outset.

Funding was initially for only 6 months which was not long enough to demonstrate any sustainable changes

The AHP profile within USC in NHS Borders has markedly increased through actual demonstration of what is possible by AHPs, and subsequent management feedback coming from other clinicians

There has been some difficulty distinguishing the identity and role of RAD

6 Essential Actions to Improving Unscheduled Care

team with that of the work via Connected Care of placing nurse care managers in A & E. RAD have worked closely with these care managers to formulate who is the best placed primary responder in any given situation and top streamline the process for A & E staff especially to avoid duplication.

RAD team have been recognised as being ‘effective’ practitioners with regard to the assessment and prompt decision making around destination of patients at the front door/ MAU.

Future considerations:

The appendix showing RAD activity highlights that the bulk of the referrals come from MAU. However, once present in the A & E department, subsequent referrals arise or are actively pursued by RAD. As a consequence of this RAD have moved their work base in to the A & E department (from April 28th) to enhance their role there.

Being based in the A & E department also supports the direction of travel towards involvement with more community based USC services such as SAS and BECS.

Developing closer links between RAD and other USC services such as SAS and BECS (Borders Emergency Care Service) could provide AHP support and assessment if indicated that this could prevent admission / readmission.

You may include graphs as appendix

Return to UnscheduledCareTeam@gov.scot

6 Essential Actions to Improving Unscheduled Care

Appendices

Appendix 1

1. RAD Activity by month

March

April May Ju

neJuly

August

Sept

OctNov Dec Jan Feb

March

0

20

40

60

80

100

120

140

160

MAU activity

A & E activity

Having a new medical consultant and a proactive designated DME consultant since late September has improved the whole MAU team approach and RAD now receive more accurate and timely referrals and assistance from the whole team in the prioritisation of referrals

A & E staff are more likely to refer ‘another’ patient once RAD are actually in the department and the decision to move the RAD team base into A & E is to improve the number of referrals to RAD.

RAD activity resulting in same day discharges/ turnaround .

050

100150200250300

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Total screened by RADTotal assessed by RADSame day discharges

6 Essential Actions to Improving Unscheduled Care

The first six months were very much about embedding the approach and awareness of the RAD team across MAU and A & E

Appendix 2

2. RAD activity resulting in same day discharges

The convergence of the numbers screened and assessed by RAD is due to consolidation of the referral criteria for RAD and increased awareness of the RAD Team’ skills.`

The % of those discharged / turned around on the same day (once assessed by RAD) has remained consistent, averaging 61 per month and 45% of the total patients assessed by them that day on MAU or in A & E

6 Essential Actions to Improving Unscheduled Care

Appendix 3

3. Age profile of front door patients seen by RAD

Age profile of patients seen by RAD

Age

<6565-74

75-84>85

In keeping with other services, RAD see more patients > 85 yrs than other groups. RAD have worked with the development of Frailty screening and pathways from the Front

Door and work closely with OPLS in decision making around a return home the same day or down streaming for further medical intervention

This demonstrates that RAD base their decision making on function and impact of medical presentation on function, rather than a person’s age.

6 Essential Actions to Improving Unscheduled Care

Appendix 4

4. Front door patients – source of referral to RAD over last 6 months

Referrals to RAD by location

MAU

EDAAU

DH

The bulk of referrals to RAD come via MAU It is hoped that basing the team in A & E will increase the workload there Day hospital patients are seen to support the Rapid Access clinic where an admission is

potentially indicated

6 Essential Actions to Improving Unscheduled Care

Appendix 5

5. Day of Care audit data - NHS Borders

6 Essential Actions to Improving Unscheduled Care

RAD team commenced on MAU in March 2015 Although the patient numbers are small, the data supports the immediate response

available from RAD for assessment on MAU from March 2015 (it is unclear whether the patient identified in Sept 2015 was a priority 4 patient or not- see criteria in appendix 6)

The graphs also show improved access to AHP assessment and intervention on wards 4 & 12 which is the subjective reporting of the AHP’s working on those wards who do not currently have to respond to A & E and MAU

6 Essential Actions to Improving Unscheduled Care

Appendix 6

6.RAD – prioritisation of workload and future considerations for service development

(

Priority 1Aligns with USC

Prevention of Admission/ Re admission - currently any patient in A & E or AAU

Priority 2Aligns withUSC

MAU patients with an EDD of 24 hrs or who require therapy assessment or intervention to facilitate a same day discharge

Telephone calls/ visits to patients discharged from A & E within the previous 24 hours (if indicated)

Priority 3More aligned to Patient Flow

MAU patients with an EDD of 48- 72 hrs, who could benefit from a therapy assessment to facilitate discharge from elsewhere in the hospital, when medically stable

Priority 4 More aligned to Patient Flow

Patients who could benefit from commencement of an AHP assessment and treatment plan to support AHP intervention further downstream e.g. for DME

Community based USC services such as SAS & BECS(future consideration for RAD involvement)

6 Essential Actions to Improving Unscheduled Care

RAD team currently work to the 4 priorities outlined above They are often expected to assess priority 3 & 4 patients but it is important

that they retain their USC focus and develop out towards community based USC services to prevent admission / readmission rather that become utilised for patient flow elsewhere in the system