ECIST conference – 4 October 2012
Effective integration of acute and community services for frail older people:
South Warwickshire NHS Foundation Trust
1. Introduction
South Warwickshire NHS Foundation Trust’s workshop will review the progress and
learning from the Trust’s ‘Cutting the Cost of Frailty’ programme, which is
redesigning a pathway for frail older people across the acute and community
services now run by the Trust, to thereby reduce length of acute stay whilst
enhancing outcomes and promoting independence for patients.
The programme’s principles - “choose to admit” only frail older people who have
evidence of underlying life threatening illness or need for surgery, early access to an
old age acute care specialist, “discharge to assess” as soon as the acute episode is
complete, in order to plan post-acute care in the person’s own home, and provide
comprehensive assessment and reablement during post-acute care to determine
and reduce long-term care needs.- were recently highlighted by the Kings Fund in
their publication on Older People and Emergency Bed Use (August 2012).
2. Aims and objectives
Following the closure of Bramcote Community Hospital, South Warwickshire
Foundation Trust (SWFT) was commissioned to expand its Virtual Ward and
Intermediate Care Services to deliver extended Community Services closer to home.
The redesign of Community Services from a 20 bedded step down unit with an
average length of stay of 36 days to a more versatile community offering of sub
acute care, where people are discharged to be assessed for ongoing services,
required a major shift in referral patterns.
The ‘Navigating the system’ project initiated this change through a collaborative case
finding approach, identifying early opportunities for inpatients to be discharged
home, supported by Intermediate Care and Virtual Ward services.
The project has resulted in 25 discharges a week (compared to six discharges a
week to the Community Hospital), improved flow management, reduction in Length
of Stay (one day for Medicine and 0.4 days for Surgery) and only 16% of people
requiring ongoing support from Social Care following intervention.
As well as the above results, the acute provider has been able to further reduce the
acute bed base by 18 beds, increase nursing levels on the remaining wards and
bring forward the deep cleaning schedule across the Trust.
The project has demonstrated the opportunities that can be delivered through
collaborative working between acute and community providers, by re-investing
resources from a bed based to a community team based model of care.
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3. Progress to date
This project forms part of a wider programme of transformational change across
Warwickshire led by South Warwickshire NHS Foundation Trust following vertical
integration of Community Services and is the first project to demonstrate tangible
outcomes.
The project forms part of the Older People/ Frail Elderly Transformation work stream,
increasing access to and improving health outcomes for older people in
Warwickshire through a more integrated approach to care delivery.
The project aims were to deliver on five daily discharges from the acute provider to
community services, building the confidence of both General Practitioners and
Consultants in the new models of care and ensuring a better use of existing as well
as new resources in the community.
There was a clear need to work very closely with the acute provider to increase
referrals to the new services and more importantly, to develop the confidence at
clinical level in the new models of care particularly for frail elderly patients as an
alternative to a bedded facility.
A project team was set up comprising of two Early Discharge Co-ordinators (both
from an intermediate care nursing background) navigating patients through the
system and a Project Manager (six month secondment) working on the ground to
lead the work streams and develop strong working relationships.
The project was divided into two work streams: ‘Green Flow’: early discharge
opportunities from the wards (Frail Elderly and Long Term Condition patient groups)
and ‘Orange Flow’:
Ambulatory Care Opportunities (Falls (no fracture or
conservative treatment), UTI, Lower Respiratory Tract Infection) in A&E and on the
short stay wards. Each work stream had Consultant, GP, acute and community
representation.
4. Project impact
The closure of Bramcote Hospital has resulted in cash releasing opportunities of
around £2,07M, £1,03M was re-invested in the virtual ward and intermediate care
services, £200,000 in four intermediate care beds within a private provider and the
remaining £840,000 offered other re-investment opportunities in the local health
economy.
In addition, the 18 bed reduction plan within the acute provider has released around
£1M net savings as well as the ability for the acute trust to improve nursing levels on
the remaining wards and bring forward the deep cleaning schedule across the Trust.
From the start of the project on the 20 June 2011 until 19 December 2011, the
project has been able to support 677 patients through community services and has
achieved a reduction in the length of stay by one day in emergency medicine and 0.4
day in Elective. Bed days lost due to delayed transfers of care have reduced from
three months to the longest delay being four weeks. Excess bed days reduced by
15% compared to an increase within another local acute provider by 8% for the
same period and similar patterns of emergency care demand.
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The referral rate to intermediate care has increased by 133% and the teams have
been able to support on average 30% of the 677 patients through the Virtual Ward,
particularly patients on the acute provider re-admissions list. Following community
services intervention, 68% of patients did not require any ongoing support, 16%
required a social care support plan, and only 0.6% were re-admitted to hospital.
The teams are now able to support a minimum of 25 discharges a week from the
acute provider, compared to Bramcote taking six to seven patients a week (average
length of stay 36 days).
5. Investment required
A project team was set up comprising of two Early Discharge Co-ordinators,
resource already commissioned within the base line and a Project Manager (six
month secondment).
The cash released through the decommissioning of the community hospital was reinvested into the intermediate care and virtual ward services (£1,03M).
The lead time between closure of the community hospital and the start of the new
service was three months, benefits were accrued immediately from the start of the
project and grew in momentum through wider health economy efficiency savings as
the project progressed.
6. Improving quality of patient care
Following community services intervention 68% of patients who were part of the
project did remain independent within their own home following discharge without
support package. Further follow up of the cohort of patients will be imminently
demonstrated through National Indicator 125: Intermediate Care patients living
independently within their place of residence 91 days post hospital discharge which
currently stands at 85%.
A Virtual Ward patient experience survey was carried out during the six months of
the project (n=87), 95% of respondents felt they had benefitted from Virtual Ward
intervention, 94% felt their Health and wellbeing had improved following intervention,
87% felt more confident to manage their condition, of the 30% of patients requiring
acute care during their stay on the Virtual Ward, 70% felt they had spend less time in
hospital due to the Virtual Ward intervention.
7. Developing the project
The project has been mainstreamed into core service delivery of the Community
Division; further work is underway to explore other ambulatory care opportunities
with support from the acute Consultants and staff through Consultant led step down
plans, an electronic version of the navigation process is due to be trialled at the
hospital to automate the case finding and navigation of patients into early supported
and recovery programmes in the wider community service offerings across health
and social care.
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8. Conclusion
The ‘Navigating the System’ project has highlighted opportunities to other local acute
providers within Coventry and Warwickshire to establish similar processes to enable
care closer to home.
The benefits realisation of the transfer of community services vertical integration of
care pathways associated with frailty and long term conditions have been sighted as
key benefits of the programme. The pathways have been designed to deliver care
closer to home and have been identified as strategically important to the GP
Consortia not only within rural North Warwickshire and Nuneaton and Bedworth but
Warwickshire as a whole.
The GP Consortia have played a key role in supporting the project and together with
the acute provider Consultants and Executive Team have embraced and relished the
new ways of working.
This whole systems approach of early identification and implementation
community support opportunities demonstrates a novel way of efficiency accrual
an austerity era and should provide other organisations with the confidence
embark on equally radical transformational changes in health and care models
benefit patients.
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Bie Grobet
General Manager- Integrated Adult Services
Integrated and Community Care Division
South Warwickshire NHS Foundation Trust
Bie.Grobet@swft.nhs.uk
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