reducing hospital admissions
DESCRIPTION
Reducing hospital admissions. Improving care for people with dementia. Whole health and social care economies Teams include patients, social care, community services, AHP’s, general practices and secondary care clinicians 20% reduction in unscheduled admissions - PowerPoint PPT PresentationTRANSCRIPT
Reducing hospital admissions
Improving care for people with dementia
QIPP Principles
Whole health and social care economies
Teams include patients, social care, community services, AHP’s, general practices and secondary care clinicians
20% reduction in unscheduled admissions 25% reduction in length of stay
Reduction in readmission within 30 days
Cornwall background
The prevalence of dementia increases markedly with age and in the UK it is estimated that some 750,000 people have dementia. In Cornwall public health epidemiological data suggests anticipated prevalence of dementia is 8536 however only 3752 of people with dementia recorded on GP QOF registers (March -11).
Care homes admissions RCHT
Total number of admissions 2009: 1654 Total number of admissions 2010: 1856
999 calls Jan 2011 227
More than 4 campaign
Identify reasons for admissions, Training needs analysis Implement training Join up systems and intelligence, Enhance and improve patient care.
Impact on clinical quality•Joined up intelligence •Educated and supported workforce•Develop what to do if flow chart for common conditions.•Awareness of disease pathology•When to call the GP•Simple nursing care procedures•Improved patient care in the right place at the right time•Safe and appropriate care to meet individual needs•Reduction inappropriate prescribing•Reduction anti psychotics•Reduction in falls•Tele-health implementation•Better end of life care•Better pain control and assessment.•Access to specialist clinicians and services:
More than 4
Nursing care home admissions audit Monthly Case note review more than 4 admissions Data collection End of life dementia pilot Care home survey Amp Tele-health
Care home questionnaire
The rationale for a countywide care home questionnaire and a review of services, was to report ‘thematically’ on the effectiveness of the current services, potential gaps and suggest improvements from the care home staff perspective.
The review made use of 30-minute telephone interviews with
care home professionals (n=27) from high and low admitting care homes.
Common themes Low admitting care homes:
•1-2 GP Practice per home•Regular ward rounds and review (many on a weekly basis).•Combination of RMN and RGN nursing staff District nurse in-reach
Support to care homes can be split into three main areas
Medical and pharmacist support Community service support Training and education
Support (continued)
Service directory for care homes 1-2 (max) GP practice per care home End of life pathway for dementiaDementia training for some GPs especially medication management District nurse and /or Community matron input and support Someone to call just to talk things through rather than call 999 Serco first, Responsive community mental health teams.
Care home audit 2009
Aim Audit : To identify the numbers of patients admitted from nursing homes with a view to:
1. Identifying the appropriateness of admission i.e. those requiring acute care (whether there is an alternative to admission to hospital).
2. Determining a care pathway to prevent unnecessary admission
3. Facilitating the patient illness journey in the best setting for the individual.
4. Considering the potential cost implications of inappropriate acute admissions of people with dementia
Methodology
A case note audit of patients with known diagnosis of dementia admitted into an acute district hospital (Royal Cornwall Hospital) from registered nursing care homes in Cornwall.
The patient cohort identified using monthly admission figures provided by the NHSCIO
Review of medical records in conjunction with a written proforma.
Key areas for scrutiny included:
1. Source of referral i.e. A&E or via GP2. Involvement of GP prior to admission3. Hour of admission4. Reason for admission / Diagnoses5. Length of stay6. Place of discharge (final outcome)7. Alternative treatment options8. Cost implications around end of life care and
admissions
Results
n221 case notes were reviewed The total number of admissions from nursing homes
to Royal Cornwall Hospital during 2009 was 534. Only those with a known diagnosis of dementia were
included. Exclusions included those attending Accident and
Emergency Dept. but not admitted, and those attending for elective surgery.
The median age for participants was 81 (range 54-104).
Source of Referrals
The number of patients referred by GP was 90 (41%), 131 (59%) were
admitted via emergency 999 service;
Pie Chart: GP Direct Admissions verses 999 Emergencies
41% (GP)
59% (999)
Break down of 999 emergency admissions
999 emergency admissions subdivided into those within and those out of standard working hours n131
70
28
6 *27*
(Admission appropriate *)
Outwith working hours 1800-
within working hours 0800-1800hrs
999 admissions
131 were admitted via 999 paramedic/ambulance services.
28 were appropriate (103 alternative options to hospital admission could have been offered.
97 admitted during standard working hours In total study (n221); 71 were admitted for end of life
care (palliative) of whom 59 (83%) were admitted via 999 services and 19 patients (27%) were admitted out of standard working hours.
GP Involvement
54% required acute care.
54
36
0
10
20
30
40
50
60
per
cen
t %
AppropriateAlternatives
available
GP admissions
Percentage of GP Admisions that required Acute Care
Reasons for Admission to RCH
Medical Conditions Number of patients (n221)
Percentage%
Infection LRTIUTIOther(ulcers/gangrene, meningitis)
39
2397
17.6
Falls FractureNo fracture
30
1614
13.6
Cardiac (MI,ACS,AF,CCF) 16 7.3
Stroke 14 6.3
Breathlessness and fatigue 11 5.2
The majority of admissions were via medicine (n195 ; 90%), the rest were a mixture of orthopaedics (n11 ; 4%) and surgery (n15 ;6%).
59% (n130) patients who were admitted to RCHT during this 11 month period did not require acute care –98 (44%) admitted via 999 services.
8 (7%) required step up care and 71 (57%) were palliative, therefore there were 41 other individuals who may have received care at home thus avoiding admission 28 of whom were 999 admissions.
Final Outcome (Discharge or Death).
70% of patients were discharged back to their
original nursing home, 4% were discharged to a step up
care and 26% died in hospital.
Pie Chart: Final Outcome for Patient Journey.
70% Back to NH
26% Died in Hospital
4% Step Up
Outcomes and Alternative Options
Alternative treatment option
Number of patients
Antibiotics 25
Intravenous fluids 4
Bowel /bladder care 4
Pain management 7
Stroke/TIA (in severe dementia) –no intervention
4
Falls prevention 10
End of Life care plan 67
Step up –place direct from community
9
Total 130 (59%)
End of Life Care
In relation to those patients with advanced terminal phase dementia, 71 (32%) were palliative.
Died in Hospital 58
(81 % of EoL subgroup)
Transferred back to Home 13
(19% of EoL subgroup)
EoL Costing ( based of non elective national tariff)
Total £143485 (over 11 months) (Mean £124504) Mean cost per person admitted for Eol care £1486.24
(£2020.92 +cc).
The above is based on PbR Tariff for 2010-11 – these figures were used to help quantify costing in real time.
Implications for Practice and Recommendations
Identifying End stage Dementia
There is a clear need to identify those with advanced terminal dementia within their care setting and instigate plans for care that are anticipatory, respectful of best interest and advocacy, appropriate to meet the needs of the individual client.
End of Life Planning
End of life planning / care pathways prevent unnecessary admission to acute care and enhance the delivery of palliative care for this client group in the care home setting.
End stage dementia Pilot
What is End stage dementia End of life dementia pilot Education to staff and carers Pathway Best Interest document
(front notes flag to Oohrs)
Allow a natural death
Response so far
Over 300 patients 7 x care homes All GPs signed up Out of hours 999 Relatives feedback positive People dying in own care home and less admissions
before death
?