Does access to an Advanced Nurse
Practitioner in times of crisis
reduce urgent care activity for
nursing home residents?
Angela Parkes
Background
Background
• Urgent care activity increasing in UK particularly for most vulnerable
• Residents of NHs have high level of need which makes them more
vulnerable
Centre for Policy on Aging (2012):
• 51% of residents were over 85
• 10% were 95 and over
• 51% were categorised as frail elderly
• 41% were categorised as requiring dementia care
Evidence
• Older residents were more likely to be conveyed to and admitted to
hospital (Crilly et al, 2011; Graverholt et al, 2011; Kruger et al, 2011; Quinn, 2011)
• People had multiple attendances (Graverholt et al, 2011; Gruneir et al, 2010)
• Interventions within home provide reductions in admissions to hospital
(Graverholt et al, 2014; Ploeg et al, 2013)
• Residents with ACP shown to have lower admission rates than those
that did not (Graverholt et al, 2014; Lamb et al, 2011; Ploeg et al, 2013)
• Medication reviews resulted in lower rates of admission (Graverholt et al,
2014)
• Access to nurse practitioners providing enhanced support. Residents
felt supported in decision making, the care was more responsive to
their needs and hospital admissions decreased (Ploeg et al, 2013)
Evidence
A number of conditions were identified as avoidable:
• Poor responsiveness (Carter et al, 2009)
• Pneumonia (Carter et al, 2009; Gruneir et al, 2010; Lamb et al, 2011)
• Urinary Tract Infection (Gruneir et al, 2010; Lamb et al, 2011)
• Falls (Gruneir et al, 2010; Lamb et al, 2011)
Local data:
• 55% of ambulance callouts related to general illness, breathing
difficulties or falls and could be avoided or minimised with increased
support
Project Overview
Pilot project overview
• ANPs who are senior decision makers supported by
Care of the Elderly consultant
• Rapid response in times of crisis
• Virtual ward rounds
• Team to deliver complementary service not replace
an existing one
• Safety of residents could not be compromised
• CCG and provider would need to evidence success
Project Evaluation
Evaluation - Data
• A&E attendances no investigation and no treatment reduced by 13%
• Only 8 emergency admissions from the homes during pilot
• Average of 0.15 admissions per home per month. Other homes averaged 2.04 per
month
• Expanding service to all nursing homes could reduce admissions by 68 per month
• Six months emergency admission costs show a reduction of £91,902
Case studies
• Edith
• Has Dementia
• Is mobile with walker
• Dizzy and pale in morning
• Low blood pressure
• Home called ambulance
• Experienced another
episode
• Team called instead
• Able to remain in home
• Continue to monitor
•
•
•
•
•
Team got there first
Assessed Edith
Diverted ambulance
Reviewed medication
Developed care plan
•
•
•
•
Tony
Advanced Parkinson’s
Lucid intervals
Preceding year 6 A&E and
2 emergency admissions
• 3 weeks later withdrawn
and unresponsive
• No infection
• End phase
• Care plan enforced
• Died peacefully 5 days later
• Team reviewed
• Discussed care with Tony
and next of kin
• Wish to remain at NH
• GP to add to palliative care
list
•
•
•
•
3 weeks later deteriorated
Urine test showed infection
Administer antibiotics
No admission required
Recommendations and
Progress
• Implement home in reach team across city
1
• Extend hours of home in reach team
2
Projected costs and savings for HIT from business case
600,000
419,741
400,000
200,000
0
-200,000
Costs
Gross savings
-400,000
-600,000
-800,000
-577,175
Net savings
-157,970
3
• Additional service that reviews medication of
care home residents
Actual costs and savings for medication review project
£60,000
£40,896
£40,000
£20,000
£0
-£20,000
Costs
Gross savings
Net savings
-£40,000
-£60,000
-£80,000
-£84,882
-£100,000
-£120,000
-£140,000
-£125,778
4
• Implement a service to ensure all residents
have advance care plans in place
HIT for
nursing
homes
Evaluate
?
GP link to
some
care
homes
References
Carter, L., Skinner, J. and Robinson, S. (2009) Patients from care homes who attend the emergency department: could
they be managed differently
Centre for Policy on Ageing (2012) A profile of residents in BUPA care homes: results from the 2012 BUPA census
Crilly, J., Chaboyer, W., Wallis, M., Thalib, L. and Polit, D. (2011) An outcomes evaluation of an Australian hospital in
the nursing home admission avoidance programme.
Graverholt, B., Riise, T., Jamtvedt, G., Ranhoff, A., Kruger, K. and Nortvedt, M. (2011) Acute hospital admissions among
nursing home residents: a population based observational study
Graverholt, B., Forsetlund, L. and Jamtvedt, G. (2014) Reducing hospital admissions from nursing homes: a systematic
review.
Gruneir, A., Bell, C., Branstill, S., Schull, M., Anderson, G. and Rochon, P. (2010) Frequency and pattern of emergency
department visits by long term care residents: A population study.
Kruger, K., Jansen, K., Grimsmo, A., Eide, G. and Geiting, J. (2011) Hospital admissions from nursing homes: Rates and
reasons.
Lamb, G., Ouslander, J., Tappen, R., Herdan, L., Diaz, S., Roos, B., Grabowski, D. and Banner, A. (2011) Interventions to
reduce hospitalisations from nursing homes: Evaluation of INTERACT II collaborative quality improvement project.
Ploeg, J., Kaasalainen, S., McAiney, C., Martin-Misener, R., Donald, F., Wickson-Griffiths, A., Carter, N., SangsterGormley, E., Martin, L., Brazil, K. and Taniguchi, A. (2013) Resident and family perceptions of the nurse practitioner
role in long term care settings: a qualitative descriptive study.
Quinn, T. (2011) Emergency admissions from care homes: Who, why and what happens? A cross-sectional study.