Frailty nurse halts the rise in unplanned admissions

30 August 2017
A specialist older people’s nurse wasted little time in proving her worth to a Gateshead practice seeking to improve services for the frail elderly and reduce their use of unplanned care.
The nurse was initially seconded from the South Tyneside NHS Foundation Trust to the Oxford Terrace and Rawling Road Medical Group in 2013 but her impact meant the practice quickly turned the role into a substantive post.
 
Using the comprehensive geriatric assessment approach, she initially developed comprehensive care plans for 94 housebound patients with an average age of 85.
 
Within nine months, emergency department visits by the cohort had fallen from 66 to 30. Unplanned hospital admissions more than halved during the same period – falling from 63 to 29.
 
These figures reversed a seemingly inexorable upward trend in emergency attendances and unplanned admissions.
 
Also importantly for the practice, the number of house calls by GPs fell by more than 80% - from 318 to 63.
 
Practice manager Sheinaz Stansfield says: “We had the test period with the older people’s nurse for six months and with those results it did not take much to convince the practice partners that we need to be doing this ourselves because we are saving appointments and money and improving patient care.”
 
Stansfield says that given her expertise it was inevitable the nurse specialist would act as a clinical leader as colleagues, patients and carers worked together to develop multi-disciplinary approaches to personalised care.
 
The benefits go further than savings in hospital resources and GP time. With the care plans accessible to other professionals in partner organisations, care is more integrated.
Stansfield says the practice and its team have benefited from the new opportunities for peer support, networking and multi-disciplinary working.
Practice staff are also working more closely with a community matron who, while still employed by the community trust, is directly linked to the practice – making her more visible and available. As the care plans of housebound patients seen by the nurse specialist have been entrenched and started to produce results, the community matron works more closely with those patients as a case manager to reduce duplication of care. This has enabled the nurse specialist to take on a steady stream of new patients.
 
The practice identified the first cohort of patients with multiple comorbidities and at high risk of unplanned hospital admission for the nurse specialist to work with by using a risk stratification tool. Around 100 of those were older people who were housebound but did not meet the criteria for access to community matrons.
 
The practice’s GPs and nurse practitioner referred around 60% of the patients to the new service while around a quarter were identified through proactive searching of data such as house calls records. The rest were encouraged to self-refer by other health professionals.
 
Stansfield argues that this proactive case management approach results in much better care and support for patients and carers than the reactive annual review that GPs are paid to conduct for each patient under the quality and outcomes framework (QOF).
 
Download the full edition of Commissioning Excellence September 2017.
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