Transcript Pro-active Care The virtual ward

Dr Phil Ridsdill Smith
Julia Davis
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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).
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Disjointed team
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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.
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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
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Non-conveyed patients more likely to be
 older
 housebound
 poorer cognition
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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.
PAC
GP Visit
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999
Visit
GP Visit
999
PRT SLAM
999
OOH GP
Clinical hunch
Admission
GP Visit
Intermediate
care
Admission
Social services
Docobo
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.
– 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
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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
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Consists of
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Format
◦ Projector and screen
◦ Review each set of
notes
◦ Review care plan
◦ Enter data as we go
All doctors
Community Matron
District Nurses
Social Services
Mental Health
Paramedics
Pharmacist
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Learning format
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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
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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)
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Multiple problems
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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
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Onto PAC 20/3/12 “very high risk of readmission”
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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
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Joined list 4/11/12
PMH
◦ Alcoholism
◦ Diabetes
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Attention over 12 months
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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
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Intervention
◦ Respite admission to Crest Lodge – more structured environment
◦ Mental Health Assessment - Chronic Alcohol Dependence – lacks capacity
◦ Deprivation of Liberty Safeguarding
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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”