dr phil ridsdill smith julia davis. good care for the most needy patients it involves: ◦ finding...
TRANSCRIPT
Dr Phil Ridsdill SmithJulia Davis
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).
Disjointed team◦ 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.
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
Non-conveyed patients more likely to be older housebound poorer cognition 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 onceSnooks 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.
VisitGP
Visit Admission
OOH GP
Clinical hunch
PAC
999 Intermediate care
GP Visit
GP Visit
Admission999999
PRT SLAM
Social services
Docobo
Out of Hours Reports checked daily, potential patient records reviewed and GP or Community Matron consulted if necessary.
Emergency Admission Listsreceived 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• 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 planwhich is then shared with OOH and IBIS
Consists of◦ All doctors◦ Community Matron◦ District Nurses◦ Social Services◦ Mental Health◦ Paramedics◦ Pharmacist
Format◦ Projector and screen◦ Review each set of
notes◦ Review care plan◦ Enter data as we go
Learning format
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
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)
Multiple problems◦ 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
Onto PAC 20/3/12 “very high risk of readmission”
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 dischargeneighbour re-laid floorReablement team went inMedicines sortedMental Health Team reviewing
Co-ordination of various teams for inputCardiology, PNs, DNs, Physio, CoE, Mental Health and Neighbours
No further readmissions, 2 further out of hours in 9 months
Joined list 4/11/12 PMH
◦ Alcoholism◦ Diabetes
Attention over 12 months◦ 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
Intervention◦ Respite admission to Crest Lodge – more structured environment◦ Mental Health Assessment - Chronic Alcohol Dependence – lacks
capacity◦ Deprivation of Liberty Safeguarding
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”