Appropriate Care Pathway

Karen Titchener MSc NMP RGN

Deputy Head Nursing Guys and St Thomas NHS Foundation Trust

Jaqualine Lindridge MA, PG Cert, MCPara

Consultant ParamedicLondon Ambulance Service NHS Trust

WHY DEVELOP A PATHWAY?

• Demand on NHS services increasing year on year with people living longer with complex co-morbidities

• Unprecedented slowdown in NHS funding leading to ambitious productivity improvement

• 5 year Forward View (NHS England 2014) why change is needed and what it looks like

• NHS England allocate funding every year for winter pressures in order of local service to help keep people out of hospital -£250000 was given to this project

London Ambulance Service NHS Trust 3

Bringing Care Closer To Home

@home is a bespoke Multidisciplinary team OFFERING

Admission avoidance and early supported discharge

• Patient centred acute care in their place of residence

• Practitioner to practitioner referral via single point access

• 2 hour response for urgent medical assessment

• Shared or total medical responsibility for patient

• Team operates 365 days of the year 8am-11pm

• Domilicary visits by consultant or @home GP when required

• Provide daily visits up to 4 times a day for 3-7 days

• Intensive Nursing, PT,OT input during intervention

Bringing Care Closer To Home

Clinical Lead

NORTH TEAM: 2 X Matron

Clinical Nurse Specialist

Senior Nurse Practitioner

Staff NurseSenior Nurse

AssistantPT/OT Pharmacist

Social Worker

SOUTH TEAM: 2 X Matron

Clinical Nurse Specialist

Senior Nurse Practitioner

Staff NurseSenior Nurse

AssistantPT/OT Pharmacist

South Ward GP

North Ward GP

2 X Consultant

GSTT: Clinical Nurse Specialist

KCH: Clinical Nurse Specialist

Bringing care closer to home

For patients with confirmed diagnosis we can offer:

• High intensity clinical monitoring, with short-term intervention in an acute episode of ill health in a safe and timely manner

• Provide urgent clinical assessment for acutely unwell patients, ECG, urgent bloods

• Initiating treatment and ongoing monitoring, IV therapy, sub cut hydration, ongoing blood monitoring, oxygen therapy, nebulisers

• Physiotherapy and Occupational Therapy intervention

• Environment check- micro environment set up

• District nursing team

• Community rehab services

• Care home support team

• GSTT AND KINGS patient pathway for 5 conditions -COPD, LVF, Cellulitis, UTI, Diabetes – early discharge

• SLAM –working with dementia team for patients with acute on chronic confusion

• Delirium pathway for care homes

• Integrated Respiratory team

• Community Heart failure service

• Service pathways with LAS.

• Learning disabilities team

• Service pathway with GSTT Obs and gynae

• Palliative care- acute and community

• Pharmacy

• Social care

@home PARTNERSHIP WORKING

Appropriate care pathway

If not time critical - phone before you go to the ED.

• Falls triggering step 3 on the falls tree with additional concern

• Acute confusion/ Delirium – manageable with @home input

• Reduced mobility/ functional decline

• Infections – respiratory, ENT and urinary tracts

• Cellulitis

• Exacerbation of COPD (consider physiological norms)

• Heart failure

• Short term social care need, inc. main carer crisis

• Palliative care crisis or urgent need

• Catheter problems (inc. supra pubic)

• Diarrhoea/ vomiting/ constipation

HOW DOES IT WORK?

• LAS CREW ATTEND 999 CALL

• On assessment crew consider @home

• Crew call @home referral line

• Clinician to clinician discussion

• @home accept referral

• LAS leave patient

• @home visit within 2 hours by GP/PT/ANP

• @home diagnosis, treat and implement care plan.

• Patient receives up to 7 day interventions

• Patient will have review by Geriatrician if required

London Ambulance Service NHS Trust 10

“It is often about getting the simple things right, that makes things work, and this proved that theory.”

COPD Nov 14 – Feb 15

Lambeth

ED:

↓ 8.13%

London Ambulance Service NHS Trust 11

LondonSouthwark

ED:

↓ 2.73%

ED:

↓ 5.47%

CASE STUDY

78 year old lady referred with exacerbation of COPD

• OE- LAS already administered salbutamol nebuliser

• Reduced mobility over last few days due to increase in SOB

• Audible bilateral wheeze bi-basal crackles,

• Marked SOB on minimal exertion

• Above knee bilateral pitting oedema

• Productive cough- white frothy

• Raised JVP

• Described- Paroxysmal nocturnal dyspnoea (PND)-no PMH of heart failure

CASE HISTORY (continued)

Treatment plan

• Oral furosemide 40mgs

• Oral abx and steriods

• Nebulisers- ipratropium bromide and salbutamol

Bloods taken: patient was found to have raised BNP suggestive of LHF

@home arranged Echo and CXR through discussion with

@home Consultant Geriatrician - showing CAP and LVF

Commenced on IV furosemide and IV abx

CASE HISTORY (CONTINUED)• After 5 days patient switched to oral diuretics

• Referral for Cardiac review

• Referred to community heart failure team for ongoing monitoring

Other interventions from @home

• assessed by @home pharmacy to ensure medications compliance and understanding of current condition and management of new regime.

• @home OT/PT review was completed yielding exercise program and ongoing referral to community PT for practice with out door mobility

• @home contacted local parish priest as patient expressed need to attend mass but due to ill health could not. The priest agreed to attend patient at home until recovery.

Multifaceted BENEFITS

• Effective and efficient integrated partnership working• Reducing A&E attendances• Reducing costs on LOS • Reducing conveyance• Improving ambulance availability• Reduced inappropriate hospital admissions• Improved health outcome for patient• Reduced risk of hospital acquired infection • Meets preference for home care over hospital • Enhances patient choice• Psychological and social benefits of comfort own home • Reduced pain and anxiety• Reduced confusion, delirium• Reduced functional disturbance

FORWARD VISION

• BIG PICTURE- Cessation of silo working and the pursuit of NHS whole system integrated approach to urgent care in order to maintain effective, safe and efficient health and social care in London that is sustainable and achievable

• @home going 24 -7 so option to expand LAS referrals

• Increase referrals through further work with LAS

• Feed back to paramedic to encourage referrals

• Emergency GP call outs to prevent LAS call out