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SHarED Implementation Guide

Acknowledgements

This SHarED Quality Improvement toolkit was originally created in March 2018 by the West of England Academic Health Science Network (AHSN) in collaboration with the Bristol Royal Infirmary (BRI), University Hospitals Bristol and Weston NHS Foundation Trust. The toolkit is based on the experience and practice of the High Impact User Team implemented in the Emergency Department at the BRI.

It was updated in 2019 for the SHarED project following a successful application to the West of England AHSN Evidence into Practice Call 2019, with revisions made in July 2020.

We would like to thank the team at the BRI for their work in the development of this project.

The SHarED Leadership Team:Clinical LeadDr Rebecca Thorpe, Emergency Department Consultant, University Hospitals Bristol and Weston NHS Foundation Trust

Senior Responsible OfficerRobert Woolley, Chief Executive, Bristol Royal Infirmary (BRI), University Hospitals Bristol and Weston NHS Foundation Trust

Senior Responsible OfficerTasha Swinscoe, Managing Director, West of England AHSN

SHarED Implementation Toolkit Contributors:Dr Rebecca Thorpe, Emergency Department Consultant, Bristol Royal Infirmary (BRI), University Hospitals Bristol and Weston NHS Foundation Trust

Angela Bezer and Johanna Lloyd-Rees, Acute Deputy Heads of Nursing (previously Emergency Department Matrons), Bristol Royal Infirmary (BRI), University Hospitals Bristol and Weston NHS Foundation Trust Sally Buckland, Jennifer MacDonald, Debbie Ottley and Raoul Chandrasakera, HIU Co-ordinators, Bristol Royal Infirmary (BRI), University Hospitals Bristol and Weston NHS Foundation Trust

Clare Evans, SHarED Programme Manager; Deputy Director of Service and System Transformations, Head of Adoption and Spread, West of England AHSN

Megan Kirbyshire, SHarED Project Manager, West of England AHSN

Lauren Hoskin and Melody Moxham, Communications and Marketing Officer, West of England AHSN

Ben Archer, Project Support Officer, West of England AHSN

Nathalie Delaney, Patient Safety Programme Manager, West of England AHSN

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I first got involved with this project because our Emergency Department Matrons had recognised there was a cohort of patients coming into our Emergency Department (ED) time and time again, with un-met health needs. Historically, it had always been easier to “patch up” these patients, and send them on their way, rather than addressing the cause of their frequent attendance.

Patients known as “High Impact Users” (HIUs) attend our ED up to eighty times per year. Mental health problems, drug/alcohol use and homelessness account for almost all of the presentations. The group has an annual mortality rate of 15%, with an average age of death in the thirties. Some service users cost £30,000 per person per year in ED attendance and hospital admission tariffs alone.

Service users report that increased ED use is associated with mental health/physical health/housing/personal/substance misuse crisis; they come to the ED because they feel they have nowhere else to turn. When we ask service users about their experience of healthcare in general, they describe health care professionals treating them without compassion and being judgmental. ED staff report that this cohort consumes large amounts of time and resources, and can be distressing for staff and other patients.

Our aim is to provide parity of esteem for all patients in the ED, and this has required an enormous cultural shift. Our aspiration is that a homeless patient attending after being found unconscious from recreational drug use, is treated with the same compassion as a patient having a heart attack. In 2014, our Matrons set up the BRI HIU service and I was asked to get involved as medical lead. We wanted an innovative system-wide approach which would improve service user experience, support staff, and reduce ED attendances and hospital admissions. We put together the HIU MDT to make bespoke plans for all of our patients. We have now expanded our team to include mental health nurses, a psychologist, a paediatric ED nurse, ambulance and police services, domestic violence advisors, as well as the core team of an ED Consultant, ED matron and HIU Co-ordinators. We now manage the top 250 patients a year.

ForewordBy Dr Rebecca Thorpe, University Hospitals Bristol and Weston

NHS Foundation Trust

Foreword


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Contents

PART 1 Introduction to SHarED1.1 Background 1.2 What is a High Impact User? 1.3 The impact 1.4 The aim of the SHarED project 1.5 Thank you letter

PART 2 The service structure2.1 The Core BRI HIU Team 102.2 Interventions 10

PART 3 The Project Structure 3.1 Project structure and the role of the Academic Health Science Network 14 3.2 The planning stage 14 3.3 Implementation of the SHarED project 19 3.4 Evaluation and outputs 23 3.5 Worked example of cost benefits 23

PART 4 Quality Improvement Resources4.1 The SHarED Driver Diagram Template 26 4.2 The Model for Improvement 27 - SHarED Quality Improvement Learning Log4.3 Demonstrating your improvement 31 - Run charts4.4 Celebrating and sharing your success 33 4.5 Sustainability 33 - NHS sustainability tool 14

a) b) c) d) e)f)

g)

Referral, triaging and prioritisationPersonal Support PlansA multi-professional approachGovernance of the Personal Support PlanSharing of the Personal Support PlanSpecific interventionsReview and discharge

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PART 5 Implementation Resources5.1 Key roles 35 • Senior Executive Sponsor • HIU co-ordinator: the champion role • HIU co-ordinator: the clinical role • Clinical Lead • ED Matron • Other stakeholders • A day in the life of a HIU Co-ordinator5.2 Patient information 40 • Patient letter • Form for patient completion without mental health needs • Form for patient completion with mental health needs • Patient letter for insertion with the Personal Support Plan5.3 Documentation 44 • Personal Support Plan template • HIU patient worksheet • Bristol EDITT (Bristol Emergency Department Impact Triage Tool)

• ICECAP-A Questionnaire• ICECAP-A Instructions for use• ICECAP-A Patient follow-up letter

5.4 High Impact User Multi-Disciplinary Team Resources 52 • HIU Project Group Terms of Reference • HIU Meeting Minutes template • GP questionnaire template • GP letter and proforma5.5 Pathway mapping 57 • Data gathering • System Alerts • HIU Referral Pathway • HIU Attendance Pathway • Complex HIU Timeline of Events and Milestones 5.6 Training 62 • What, where, how?5.7 Communications 62 • Communications plan • Example email to ED Staff for launch of service • Posters and aide memoires 5.8 Checklists 65 • Get Ready for SHarED • SHarED Launch Checklist

PART 6 Glossary and abbreviations 67

Contents


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Introduction

This guide has been developed to support the implementation of the SHarED (Supporting High impact users in Emergency Departments) Project in local Emergency Departments. It is based on the experience of the Bristol Royal Infirmary (BRI) team, University Hospitals Bristol and Weston NHS Foundation Trust, in implementing a High Impact User Team in to the Emergency Department.

SHarED is the name of the spread project for implementing the BRI High Impact User model in to other Emergency Departments, led by the West of England Academic Health Science Network (AHSN).

The majority of resources available in this toolkit are made for immediate use; however they may require some adaptation to suit the local implementing site and have been designed accordingly.

All resources are available online at www.weahsn.net/shared

It may be helpful to look at the Quality Improvement section of the West of England AHSN website: www.weahsn.net/qi

http://www.weahsn.net/shared

http://www.weahsn.net/qi

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1.1 Background1.2 What is a High Impact User?1.3 The impact1.4 The aim of the SHarED project1.5 Thank you letter

PART 1Introduction to SHarED

PART 1 Introduction to SHarED


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Patients who repeatedly attend healthcare facilities represent between 1-2% of Emergency Department attendances annually. Literature suggests these patients also frequently access other health and social care facilities, generate greater admission rates and a have greater burden of chronic disease.

Furthermore, frequent attendance at Emergency Departments is known to be associated with increased stress and dissatisfaction amongst patients. The mortality rate is double that of the “average” population. This cohort has a higher burden of alcohol and substance misuse, and psychiatric illness.

The Royal College of Emergency Medicine (2017) has published guidance for managing this group of patients including a multi-disciplinary approach with a senior decision maker reviewing attendances and developing management plans, accessible by all health care staff within the hospital.

In April 2015, the BRI High Impact Users (HIU) Team was formed to tackle this exceptionally vulnerable cohort of patients. The work was initially completed in addition to existing workloads. In 2018 the HIU Co-ordinator role was officially funded to support ongoing work.

1.2 What is a High Impact User?High Impact Users can be defined in a number of different ways:

1. On the basis of frequency of attendances - The Royal College of Emergency Medicine (RCEM) define a frequent attender as anyone who has five or more attendances to the ED per year.

2. On the basis of impact on the department - anyone who has a significant impact on departmental resources for any reason, including medical and nursing needs, social needs or behavioural problems.

3. A person with a complex medical condition, mental health problem, chronic illness, or a social situation which results in repeat hospital attendances and/or admissions.

4. In the BRI, the term “super user” is defined as a user who has attended the ED 20 times per year or more.

1.1 Background

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During the first year of operation, the team reviewed the outcomes for the “top 100” frequent attenders and discovered that the mortality rate was 15%; the average age of death was in the forties. Deaths were due to a combination of reasons:

• Sudden unexplained death • Presumed suicide • Drug toxicity • Medical causes e.g. throat cancer • Hypothermia • Alcohol withdrawal seizures • Recreational drug use • Alcohol intoxication

This very high mortality rate in a young population is significant. The one-year survival rate in this group is 85%. This is similar to survival rates to some malignancies such as laryngeal cancer, and significantly worse than survival rates for breast and prostate cancer.

Over the first year, a total of 26 patients were discussed and managed at the MDT meetings. Of these patients, 24 had a significant reduction

in ED attendances after intervention, such that they were no longer classified as a frequent attender. Two patients were more complex cases and remained on the HIU MDT caseload for ongoing management at the end of the year.A further 20 patients with predominantly chronic medical problems, were managed by a subgroup of the HIU Team - the ED consultant and specialist teams to produce individual personal support plans (PSPs). All of these patients have significantly reduced their attendances, with no adverse outcomes noted. A further 50 patients were managed by a combination of ED Consultant, drug and alcohol specialist nurses, and Liaison Psychiatry. These patients are usually those who do not get allocated a space at the MDT due to resource limitation; they have been identified as having chronic drug/alcohol/mental health problems, that could be better supported, in such a way as to optimise their care and avoid ED attendances.

In total over the year first, over 50 PSPs were written. These are reviewed annually for every patient, or sooner if indicated.

PART 1 Introduction to SHarED

1.4 The aim of the SHarED projectThe aim of the SHarED project is to reduce Emergency Department attendances by High Impact Users managed under the High Impact User Team by 20% and to improve the experience of High Impact Users and Emergency Department staff in one year.

1.3 The impact


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Dear BRI A&E

I just wanted to write and say thank you and sorry.

Thank you for looking after me all the times I came in after self harm or overdoses. You were always really kind and patient with me.

Sorry I used to come in so much, and used up one of your beds. I know you’re busy and it was so selfish of me to do it all the time. I was in a real bad patch and I didn’t have anywhere else to go. My mental health team had discharged me, and I was living in a hostel, in a new city away from my family. I didn’t exactly like coming in all the time, and I used to feel really bad for wasting all your time, but at the time, I thought you were the only people that really cared about me. I remember sitting in the waiting room watching how busy you all were, and hating myself for being such as waste of space.

When you started to help me get the support I needed, and putting me in touch with all the right people, I realised I didn’t have to live like that for ever. I was allocated a care co-ordinator and started making an effort to get to my appointments and do the right thing. I’ve now managed to stay off drugs and alcohol, and when I did that, they found me somewhere safe to live, and now I’ve even got a job – helping other people like me, as a support worker! I’ve got an amazing partner, and we’re planning on getting married next year.

But I just wanted to say thank you for sorting me out and giving the chance to get my life back. You hear lots of bad things about the NHS but I think the BRI is full of amazing people, so thank you.

1.5 Thank you letter from a service user


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2.1 The Core BRI HIU Team2.2 Interventions

PART 2The service structure

a) b) c) d) e)f)

g)

Referral, triaging and prioritisationPersonal Support PlansA multi-professional approachGovernance of the Personal Support PlanSharing of the Personal Support PlanSpecific interventionsReview and discharge

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This section outlines the structure of the HIU team as it is set up at the BRI. When implementing the SHarED model, there may be some variations in your set up to suit your local services. However, the core principles of the structure should be applied.

2.1 The Core BRI HIU TeamThe core HIU team consists of: • ED Matron • ED Consultant

• HIU Co-ordinators (in the BRI, there are two Band 7 whole time equivalents from a variety of clinical backgrounds)

• Administrative support

The extended team may include representatives from Clinical Specialities, Drugs and Alcohol Teams, Homeless Teams, Domestic Violence Workers, Liaison Psychiatry, GPs, Police, Ambulance Services and Safeguarding Teams. It may also be appropriate for the HIU teams from neighbouring trusts to attend.

2.2 InterventionsThe below interventions are also summarised in the process maps in section 5.5.

a) Referral, triaging and prioritisation:

Internal referrals can be made to the HIU team via email or through the electronic referral systems. The referrals are then reviewed and prioritised alongside the patients on the list of the top attenders, as described below.

The HIU Co-ordinator will triage patients using the Bristol EDITT (Bristol Emergency Department Impact Triage Tool, see page 47) which assesses the patient’s level of risk and their attendance in the last year. It is important to note that The EDITT Tool has been developed locally by the HIU Team and has not undergone validity/reliability testing at this stage. Additionally, the tool is designed for local use in the BRI and therefore will need to be adjusted to suit local needs.

Quality Improvement techniques will be used to test Bristol EDITT in each trust and compare local tools. A comprehensive instruction document for this can be found on the SHarED webpages of the West of England AHSN website.. The number of patients on the HIU caseload at any given time is variable and dependent on the complexity of the service users. After patients have been triaged, they are prioritised according to the frequency of the recent attendances and the level of impact on the emergency department, alongside the EDITT Score. (See page 38 for a visual representation of the referral process into the HIU service). Throughout the SHarED project, an average of six patients will be triaged and prioritised each month.

PART 2 The service structure


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Whilst acknowledging that patients may not have a fixed address or may have difficulty with literacy, a standardised letter (page 40) will be sent to all appropriate patients along with a questionnaire for them to complete (pages 41 and 42). A letter will also be sent to the GP (page 55) alerting them to the fact that the patient is a frequent attender. A questionnaire is included with the letter to assist the GP in involving the patient in the process (page 54).

b) Personal Support Plans

Personal Support Plans (PSPs) (page 44) are written for all selected individuals using a multi-disciplinary approach. They are guides for clinical staff to describe the patients normal presentation, how best to respond and de-escalate certain behaviours and support recovery, for example:

• Patients who present frequently reporting self-harm are consistently encouraged to contact community services designed to support them, rather than being referred to on call Liaison Psychiatry Services during each ED attendance.

• Signposting of patients with chronic drug and alcohol problems to Community Services.• Patients who present with physical symptoms who have been subject to multiple, thorough

investigations with negative results are encouraged to manage their symptoms with simple measures. Clinicians are empowered to avoid repeated, potentially harmful over-investigation and hospital admission – which all have potential risk of iatrogenic injury.

• Consideration for social prescribing where appropriate via primary care.

c) Multi-professional approach

Multi-disciplinary meetings are to be held monthly where a maximum of 10 patients will be discussed. The group is designed to facilitate discussions around the selected patients using the ED clinical notes and supporting information from specialist nurses, primary care and other representatives. All management plans involve the patient’s Consultant, ED Consultant, G.P. Specialist Nurse and any other relevant agencies and specialists. They are shared with the G.P. and patient (when appropriate), and then uploaded onto the electronic patient record system.

Relevant specialties are involved to risk assess and provide safe management plans for patients with chronic medical problems, for example:

• Open access to “hot clinics” to prevent patients reaching crisis point and needing to phone 999• Remote monitoring e.g. of cardiac defibrillators with phone support by cardiology services• Community Matrons conduct home visits and monitor chronic disease• Palliative care hospice outreach involvementd) Governance of the Personal Support Plan

As the PSPs can be high risk with difficult decisions made, the governance process below is followed:

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e) Sharing of Personal Support Plans

Once the PSP has been written and agreed by the team, it is to be published on the Electronic Record System and shared to offer patients a consistent approach for when they access any local service. It is recommended that you share patients that are on your list with neighbouring trusts who also run a HIU service, in order to improve the care patients receive across the city.

If PSPS can be automatically uploaded on to the data sharing systems such as Connecting Care, they can be accessed by other Emergency Departments in the city, Primary Care, Out of Hours Primary Care, walk in centres, urgent care centres, the ambulance service and local police service (via Control Room triage). This facilitates a consistent approach from all services.

The PSP should also be shared with the patient, to provide them with the opportunity to review and comment as is their right. This can be done in writing, and also opportunistically by the HIU co-ordinators when the patient attends the ED.

f) Specific interventions

When developing the PSP, you may wish to consider referrals to specific services such as:• Medically Unexplained Physical Symptoms (MUPS) clinic, run by the Liaison Psychiatry team• Mental Health Services• Cardiac Psychology team through liaison with the GUCH team

g) Review and discharge

Each patient should be reviewed monthly until their presentations reduce to an acceptable level, agreed according to the current level of demand, or after all possible interventions have been attempted. They are then removed from the MDT list, but are monitored to pick up any subsequent increase in attendance rates. Plans should be reviewed annually and archived if no longer active.

PART 2 The service structure

Personal Support Plan is written

Reviewed by a minimum of two other members of the team:HIU co-ordinator or ED Matron AND Lead HIU ED Consultant (all PSPs to be signed by the ED consultant with the exception of patients whose PSP is predominantly social).

Copy sent to any other contributors (for example: care co-ordinators/medical specialist/specialist nurses/homeless support team) for their approval

PSP completed to document who it has been written and verified by, and the review date.

1 2

3 4


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3.2 The planning stage 3.3 Implementation of the SHarED project 3.4 Evaluation and outputs 3.5 Worked example of cost benefits

PART 3The Project structure3.1 Project structure and the role of the Academic Health

Science Network

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PART 3 The Project Structure

3.1 Project structure and the role of the Academic Health Science NetworkThe overall structure of the project is based on the ‘Breakthrough Series Collaborative’ model developed by the Institute for Health Improvement. This involves a series of collaborative meetings with coaching, calls and teleconferences in between. The aim of the meeting is to share failures and successes, understand how barriers have been overcome and to learn from data.

The Academic Health Science Network (AHSN) is a network of 15 organisations throughout England, who link all healthcare organisations in a region to improve healthcare at pace and scale.

3.2 The planning stageSee “Part 4: Quality Improvement Resources” section, page 25, for further details.

A key factor to gaining engagement with the project is to invite input from all staff involved in the pathway from the very beginning. Having agreed the aim, brainstorming with the group about what is required and listening to all views is important for good engagement. Using tools, such as process mapping or developing a driver diagram, may be useful as part of the planning stage.

A driver diagram is a visual way of breaking down the stages of the project, as well as using the overall Project Plan mentioned above. The driver diagram can act as a personal project plan, and although the aim and measurement strategy will be the same for all organisations, the details of the driver diagram in terms of actions required to achieve the goal might be different for individual teams.

The SHarED project driver diagram is on the next page. There is a blank template in the resources section (page 25) so that you can create your own diagram with your team.

The West of England AHSN will use the Project Plan available online to support and track progress of the project.


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These following steps outline vital components of the planning process: stakeholder engagement and data collection and measurement strategy.

Step 1: Stakeholder engagementSet up a multi-disciplinary team (MDT) to include all roles involved in the process. Each person should have defined roles and, in particular, ensure that effective communication is fed back to each discipline. An example Terms of Reference for the MDT can be found on page 53.

Nominating an Executive Sponsor for the project is also a vital element, plan to keep them briefed regularly. This can be important to unlock difficult obstacles if they arise. All chief executives are aware of SHarED.

Regular meetings to review progress and discuss issues are important to ensure the practicalities of the project are being addressed, staff are being supported and messages are being appropriately disseminated. Frequency of these meetings can be decided by the project lead and alternative ways of communicating such as posters, email and presentations at relevant meetings can also be effective.

Suggested inclusions in the MDT are:

• Clinical Specialities

• Drugs and Alcohol Teams

• Homeless Team

• Domestic Violence Workers

• Liaison Psychiatry

• GPs

• North Bristol Trust HIU Team

• Police

• Ambulance Service

• Safeguarding Team

Step 2: Data collection and measurement strategyDevelopment of a robust measurement strategy is important for co-ordination of the project. This ensures progress is tracked and maintained and any difficulties addressed and can be documented using a measures checklist if helpful.

The strategy should include:i) The type of measures that you will be collecting and their definitionsii) Your data collection method iii) How you will present your data

i) Type of measures and definitions: The measures for SHarED have been fully defined in the measurement strategy (page 11), categorised as outcome, process and balancing measures.


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It is important that you collect baseline measures for outcome and process measures before starting the project. Baseline measures are essential so that you can demonstrate any change in outcome and demonstrate improvement in the processes to achieve the improved outcome. In the instance of the SHarED project, the baseline measures will consist of the number of ED attendances and hospital admissions for all selected patients for one year prior the the PSP being started. Although it is useful to be able to compare data between trusts, it is important to remember that the data you are collecting is for improvement in your organisation, rather than for comparison or benchmarking, as each organisation is different.

Alongside the quantitative data collection, two methods will be used to gather qualitative feedback about the HIU service:

• To assess the impact of the HIU Service on the Quality of Life of HIUs, the ICECAP-A Questionnaire (see pages 48-51 for instructions for use and the resources) will be completed with the patient before implementation of the plan and 6 months post implementation.

• The staff in the ED will be requested to answer a Culture Survey online. This will work to establish to cultures specifically around HIUs and amongst all staff in the ED, including both clinicians and adminstrative staff of all bandings. This will be sent out by the Clinical Leads at the start of the project, at the end of the project funding and at one year.

ii) Data collection method:Consideration needs to be given to how data will be collated.• How are the measures going to collected (paper, electronic, telephone, postal)• Who is going to collect them? Allocating responsibility adds reliability and ownership of measures, thereby

increasing chance of achieving success. Measures may be collected by different people depending on availability of staff in your organisation. For example:

o HIU Co-ordinatorso The Clinical Leado Admin staffo QI audit departments o Input might be needed from IT for electronic systems or admin support to post out the questionnaire o and input the returned information

Data collection needs to be reliable and continuous. Do not rely on one person to do this; it must not be person dependent.

iii) Displaying your data Decide how you are going to display and feedback your data and to whom. Allocate responsibility for this.

Present baseline measures, such as the development of PSPs and the number of staff trained, to stakeholders to win ‘hearts and minds’ and help engage stakeholders in valuing your project as a necessary change. Due to the nature of working with HIUs the changes with their behaviour can take some time, and so it may be a few months before you can start to demonstrate improvements in their attendances. Presenting a patient story from your organisation is also very helpful forgetting staff on board.

An infographic has been developed to support this, as discussed, on page 21.

PART 3 The Project StructureSHarED Implementation Guide

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In addition to the local data set outlined above, there will also be a high level data set that will be provided by the Business Intelligence Teams in each trust using parameters defined as:

‘Patients who have attended the Emergency Department five or more times in the last 12 months, with their last attendance being in the last three months. For these patients, the following data is required: age on most recent attendance, number of attendances in previous year (365 days), all diagnoses on most recent attendance and all investigations on most recent attendance.’

It is up to the High Impact User (HIU) Co-ordinators to decide if they wish to be involved in the collection of this data; the West of England AHSN can be in direct contact with the Business Intelligence Team if preferable.

This data will support a review of the overall number of HIUs in each trust and will enable us to theme the reasons for attendance to help understand differences in geographical areas. The themes are social, physical, mental health, addiction, Learning Disability or ‘no diagnosis’. The West of England AHSN will be responsible for theming the diagnosis with guidance from the team at the Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, where required.

Prior to the COVID-19 pandemic, this data was to be collected only at the start of the project and at the end of the project funding. However, this has now been expanded to allow for high level evaluation of the impact of COVID-19 on HIUs.

3.3 Implementation of the SHarED project 1. Test in a small group first:PDSA stands for Plan-Do-Study-Act. This means doing small tests of change and understanding what works before changing your system. Details of how to do this are in “Part 3: Quality Improvement Resources” on page 18.

Ideally start testing how one or two changes to the service work before making further changes. For example, this may mean implementing and gradually improving the referral mechanisms to the HIU Service and reviewing how effective each improvement has been. Ensure all relevant staff members that are fully informed before the start of the case and have been asked for feedback so they feel involved in the change. The important part of doing small PDSAs is to learn from what happened:

• What went well and should be repeated?

• What could have made things easier?

Add these to the plan for making the next change.

2. Ensure the changes are delivered and audited:Adapt processes as you learn from testing the changes and listen to staff feedback. In doing so, the team will feel ownership of the change which in turn will help sustain the change in the long term. You may want to review how effective your referral mechanisms are through auditing referral routes, or audit how frequently staff are checking for PSPs. The data can then be fed back to the ED team to show how well implementation of the service is going.



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Data Collection Dashboard

The dashboard below has been developed to support your data collection. Once populated, the dashboard will demonstrate your progress with development of plans and staff training.

Once the number of ED attendances have been recorded, a run chart will be produced to show how effective the PSP has been.

Full instructions on how to use this are included within the dashboard in the ‘Instructions of Use’ tab.


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Review and feedbackFeeding back in a simple way to the team and other stakeholders is important to maintain momentum and support. Displaying progress with the plans and the staff training is a simple and effective way of visibly seeing overall development of the SHarED project. An infographic can be printed directly from the dashboard and put up in your staff areas.

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Once you can start to see improvements in attendances, you may wish to share the run-charts with ED staff to show effectiveness of the service. The run-chart can be annotated to show when the PSP was implemented. An example is shown below.

Further information is available in the Quality Improvement section on page 25. Ensure that you are regularly reviewing your data and effectiveness of each component part of the HIU Service, as well as ensuring all staff members are informed of the progress of the work. Any difficult issues can be recorded and plans to un-blocking discussed before progressing the work further.

3. Celebrate successDon’t forget to celebrate success as you go and thanking staff has a great impact on engagement and sustainability. Cakes go a long way!

Sharing results in a newsletter and showcase in coffee rooms to make sure success is shared. Don’t forget to showcase to your executive sponsor as well!


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3.4 Evaluation and outputsThe aim of the SHarED project is to evaluate the effectiveness of the SHarED service in each trust using the qualitative and quantitative data collected that will be collected. The SHarED project will also work towards long term embedding of the service through supporting you to build a local business case.

3.5 Worked example of cost benefitsThe HIU team at the BRI have developed a means of establishing the cost benefits for the HIU Service, as shown below.

Outcome:ED attendances are reduced:• From an average of 48 per person annually to 9 per person annually.• Annual ED attendances reduced from 241 per year (for five patients) to 45.• 82% decrease in ED attendances.

Hospital admissions are reduced:• From an average of 65 per person annually to 12 per person annually.• Annual hospital admissions reduced from 65 per year to 12.• 82% decrease in hospital admissions.

Taking into account only ED attendance and medical admission tariffs showed their total annual cost in 2015- 2016 to be £93,813 (for all five patients). When tracked prospectively through High Impact Users intervention process, and their attendance and admission patterns for the following year, these costs were reduced to £16,419 annually; a saving of £77,394 in these five patients alone.

Workload:A conservative estimate of the completed workload in the year 2015-2016 is below:

Preparation:• Four hours ED matron.• One hour each for other members.• One hour meeting monthly. Care plan formulation:• One hour notes review per patient each for ED Consultant plus other specialties (Liaison Psychiatry, Drug/

Alcohol Services, medical Consultant).• Discussion and documentation of care plan onto Medway: twenty minutes per patient.• Communication with GP:ED Consultant: varies from ten to thirty minutes per patient.

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Estimation of total workload in first year• MDT meeting: 12 hours per each core member (12 one hour meetings annually) = 60 hours in total• PSP preparation: 50 hours per each member (one hour each for 50 patients) = 150 hours in total• PSP formulation: 16.7 hours per each member (20 minutes each for 50 patients) = 50 hours in total• Communication with GPs: minimum 13 hours (minimum 10 minutes each for 50 patients needing care

plans, and additional 30 patients discussed at HIU MDT) done by ED Consultant = 13 hours total Total work load = 273 hours annuallyDue to resource limitation, we can only discuss ten patients at our MDT each month. Some patients remain on the “top ten” list for several months as their management plan can be very complex and require a multi-agency approach. This prevents other, extremely high impact users from benefiting from the process.

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PART 4 Quality Improvement Resources

4.1 The SHarED Driver Diagram Template

4.2 The Model for Improvement - SHarED Quality Improvement Learning Log4.3 Demonstrating your improvement - Run charts4.4 Celebrating and sharing your success4.5 Sustainability - NHS sustainability tool

PART 4Quality Improvement Resources


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4.1 The SHarED Driver Diagram templateThis template can be completed to assist you with planning your actions that are required to successfully implement the HIU Service and achieve the project aim.

The Primary Drivers in this template are examples and can be edited to your local project.

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4.2 The Model for Improvement In order to implement a change in a sustainable way in your organisation, and to be able to measure the impact of this intervention, we recommend a structured Quality Improvement framework for implementation.

Quality Improvement science is the application of a systematic approach using specific methods and techniques in order to deliver measurable improvements in quality, care and safety.

The processes we describe can be adapted to meet the needs of staff, service users and organisational context. Our approach uses the methodology developed by the Institute of Health called the IHI Model of Improvement.

You can find out more about the Model for Improvement through the MINDSet quality improvement toolkit. MINDSet quality improvement toolkit. Although aimed at people involved in providing and commissioning services for people with mental health projects, it is an excellent resource for practical quality improvement guidance.

Other useful resources include an introduction video to PDSA cycles and the Institute for Healthcare Improvement Website.

http://mindsetqi.net/

https://youtu.be/xzAp6ZV5ml4

http://www.ihi.org/resources/pages/howtoimprove/default.aspx

http://www.ihi.org/resources/pages/howtoimprove/default.aspx


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If you have any immediate clinical concerns regarding a patient’s safety or wellbeing please escalate via normal channels.

SHarED Quality Improvement Learning Log The purpose of the learning log below is to record implementation activity, learning and reflections from implementation of the SHarED project, through PDSA cycles, to:• Capture lessons learnt• Inform the approach of future improvement initiatives and• Contribute to the evaluation of ShareD


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SHarED Quality Improvement Learning Log

PDSA Cycle Number: Date: Author:

Aim: What are you trying to accomplish? What issue would you like to improve

Plan: What will your test be? How could the issue be resolved? What could be introduced to make an improvement? Who is a useful contact to support you with this improvement? What data will you collect to know if the change has made a difference?

Prediction: What do you think will happen as a result of your test?

Do: What happened when you carried out your test? What did the data show?

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Study: How did the results of your test compare with predictions? Has the change been an improvement? What have you learnt from making this change? Do you have any tips for other improvers?

Act: Next steps: Is there still room for improvement? What will you do next?

Learning and reflections: What worked well? What would you do different next time? Any other points to record?


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4.3 Demonstrating your improvement - Run chartsRun charts are line graphs where a measure is plotted over time, often with a median (the middle value of those plotted so that half are above and half are below) also shown. Display of the data in a run chart, demonstrating the change in compliance over time, is a very visual way of demonstrating improvement. They allow us to:

• Display data to make process performance visible • Determine if a change resulted in improvement • Assess whether improved performance has been sustained

Changes made to a process are also often marked on the graph so that they can be connected with the impact on the process.

Ideally a minimum of 20 patients a month should be sampled or all of the patients if you have less than that. Sampling smaller numbers has also been shown to be an effective and reliable way of obtaining data where data for all is not easily available, and it allows for continuous repeated data collection.

Data should be reviewed each month so you understand what is happening and any issues can then be addressed promptly, as in the example above when there was a decrease in the availability of fluid warming devices.

Displaying data in run chart format is not only useful as a visible demonstration of the impact of your changes but can also be used to demonstrate whether any improvement is significant and that processes have become more reliable, if the variation between data decreases.

Run Chart RulesRun charts are a powerful tool for detecting special cause (non-random) variation. If there are at least 10-12 data points on the graph, run charts can also be used to distinguish between random and non-random variation using four simple rules.

1. A shift: six or more consecutive data points either all above or below the median. Points on the median do not count towards or break a shift. This suggests there has been a genuine change.

2. A trend: five or more consecutive data points that are either all increasing or decreasing in value. If two points are the same value ignore one when counting. This is a good sign and might demonstrate that the PSP is working and that change is happening although not yet established.

3. Too many or too few runs: a run is a consecutive series of data points above or below the median. As for shifts, do not count points on the median: a shift is a sort of run. If there are too many or too few runs (i.e. the median is crossed too many or too few times) that’s a sign of non-random variation.

4. An astronomical data point: a data point that is clearly different from all others. This relies on judgement.


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It is important to understand the reason for special cause variation and not to react unnecessarily to one-off changes in the behaviour of a process. Analyse the chart by studying how values fall around the median. Below are some examples of run-charts and their corresponding rules.

Further information can be found in the NHS Improvement resources ‘Making Data Count: Getting Started’ and ‘Making Data Count: Strengthening Your Decisions’.

https://improvement.nhs.uk/documents/2748/NHS_MAKING_DATA_COUNT_2019_FINAL.pdf

https://improvement.nhs.uk/documents/5478/MAKING_DATA_COUNT_PART_2_-_FINAL_1.pdf

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4.4 Celebrating and sharing successThis is important to maintain engagement with the teams. There are various ways of communicating with the teams, such as newsletters and notices. Remember to feedback to divisional leads and your executive sponsor.

4.5 SustainabilitySustainability means ‘holding the gains and evolving as required, definitely not going back’ and needs to be thought about from the beginning of the project.

A project has increased chance of being sustained if:• Team engagement is encouraged from the beginning• The team have ownership of the change and have had input into it• The team understand the need for change and have visible feedback on progress• Senior leadership and organisational engagement are visible• New processes are added to existing processes that are reliable• Processes do not rely on one person and reliable processes are in place for change-over of staff if

necessary • Making the new processes as easy as possible (‘making it easy to do the right thing’) – embedding

processes into your electronic system can support this.

The NHS Sustainability ToolThe NHS Sustainability Tool utilises many of these factors and is useful to do with the team at the beginning, middle and end of the project and can guide you as to which areas to concentrate on. The AHSN can support you with this.

This guide will serve to support the drive to improve outcomes for HIUs and reduce their attendance to the Emergency Department. Implementation and development of the first PSPs is likely to take approximately three months, and therefore improvements will not be seen immediately. However, once in place reduction in attendances should be apparent within a few months.

Writing a business case will be a key milestone for the project team to work towards securing ongoing funding. Both qualitative and quantitative data will be required to support this and sufficient time lapse since the start of the project will be required to ensure data is available.

https://improvement.nhs.uk/resources/sustainability-model/


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This section contains templates and resources that you may find helpful in the implementation of your HIU service. All resources are available on the West of England AHSN website and can be adapted for local use. Go to: weahsn.net/shared

5.1 Key roles • Senior Executive Sponsor • HIU co-ordinator: the champion role • HIU co-ordinator: the clinical role • Clinical Lead • ED Matron • Other stakeholders • A day in the life of a HIU Co-ordinator

5.2 Patient information • Patient letter • Form for patient completion without mental health needs • Form for patient completion with mental health needs • Patient letter for insertion with the Personal Support Plan

5.3 Documentation • Personal Support Plan template • HIU patient worksheet • Bristol EDITT (Bristol Emergency Department Impact Triage Tool) • ICECAP-A Questionnaire • ICECAP-A Instructions for use • ICECAP-A Patient follow-up letter

5.4 High Impact User Multi-Disciplinary Team Resources • HIU Project Group Terms of Reference • HIU Meeting Minute Template • GP letter template • GP template for completion

5.5 Pathway mapping• Data gathering

• System Alerts • HIU Referral Pathway • HIU Attendance Pathway • Complex HIU Timeline of Events and Milestones

5.6 Training • What, where, how?

PART 5Implementation Resources

5.7 Communications • Communications plan • Example email to ED Staff for launch • Poster: Think SHarED

5.8 Checklists • Get Ready for SHarED • SHarED Launch Checklist


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5.1 Key rolesThe appointment of key roles for the programme is a key milestone to achieve. Once local lead roles are in place, the link matron from UH Bristol and the West of England AHSN will support teams to understand their baseline data, assess their quality improvement capability and capacity and progress toward developing an achievable timeline for a launch date.

The following roles are essential in the implementation of the HIU Service:• Senior Executive Sponsor • HIU Co-ordinator – The Champion Role• HIU Co-ordinator – The Clinical Role• Clinical Lead• ED Matron• Other stakeholders• Link Matron from UHBristol

Senior Executive Sponsor

We would recommend having a Senior Executive Sponsor to raise the profile of this work and troubleshoot when problems arise.

HIU Co-ordinator – the Champion Role

The HIU Co-ordinator will act as the primary local agent to successfully embed the HIU Service. In order to do this, the post-holder will fully understand the background and requirements and will champion the project within their own department and Trust. She/he will complete the following:

• Develop a working plan in partnership with the UH Bristol Link Matron:• Identify the resources needed • Agree schedule of contact with the Link Matron• Promote the embedding of the service within their own Trust• Attend the SHarED project breakthrough workshops

• Develop a local implementation plan including:• A project timeline• Identifying the most appropriate tools, documents and resources to implement in to the local

pathways from those provided

• Develop a high level communication plan through:• Identifying the most effective ways to engage staff in training and communication (will vary

dependent on staff) • Identifying and engaging key stakeholders locally• Identifying how and when the wider MDT will be engaged. • Working with the trust Communications Team

• To seek support and report to the SHarED Project Team • Attend monthly SHarED project teleconferences with the other trusts

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PART 5 Implementation Resources

• Work with the clinical lead to develop a business case to work towards long term sustainability of the project

• Be responsible for the data collection around the HIUs and inputting in to the SHarED Trust Data Dashboard, and share the data with the SHarED Project Manager as requested by West of England AHSN on a monthly basis once 10 plans have been started

• Be responsible for the collection of ICECAP-A Survey and record the results in the SHarED Trust Data Dashboard

• Escalate issues to the Clinical Lead and Senior Executive Sponsor.

HIU Co-ordinator – the Clinical Role

• To identify people presenting as HIUs to the emergency department

• To identify the causes of frequent attendance to the ED by thoroughly checking records and notes available

• To triage High Impact Users via EDITT (or your locally agreed triage tool) to assess priority of PSP formulation

• Co-develop PSPs for HIUs with other specialist teams and organisations within the MDT for use in the Emergency Department in order to inform staff and address individual patient needs

• Ensure safe, appropriate, effective and sustainable care for the individuals through the use of PSPs

• Provide high quality nursing experience and clinical advocacy to meet the needs of the patient

• To liaise with internal and external specialist teams, according to their involvement with the service user, to identify needs and solutions

• To monitor and update existing PSPs as required/annually

• Governance of PSPs including regular updates

• To hold and chair regular multi-agency HIU Meetings

• To send letters to service users to inform them of the process and invite contribution to their PSP by completing the questionnaire or meeting to discuss

• To contact patients GP to invite contribution

• To deliver regular training sessions to the ED staff and promote a positive culture around HIUs

• To act as a point of referral for other members of staff

• Report writing and data collection, for example contribution to the annual ED report, risk management reports, complaint reports


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Clinical Lead

This role requires clinical experience, particularly working with HIUs, credibility and leadership skills. Working collaboratively across existing ED networks is desirable. The HIU medical lead role has developed over the last few years to the below:

• Providing day to day medical leadership to the project

• Reviewing and verifying every PSP written by the HIU Team, with the exception of patients whose PSPs are predominantly social

• Liaising with medical/surgical specialties on an individual patient basis where required to assist in developing the PSPs

• Risk assessing individual cases

• Liaising with Trust legal team regarding patients as necessary

• Championing of project on the shop floor including raising awareness of the HIU Team at ward rounds, handover and when supervising junior doctors and Emergency Nurse Practitioners (ENPs)

• Writing and presenting reports including annual HIU activity report, contributing to business cases for funding to make the team sustainable

• Presenting project work in a variety of formats to ED staff including formal teaching sessions and junior doctor induction

• Working with other EDs within professional networks and liaising with ED consultants/HIU clinical leads in other EDs to make joint plans for patients who are users of multiple EDs

• Briefing the Executive Sponsor on progress, success and challenges

• Be responsible for sending out the Culture Survey to ED staff

ED Matron

• Direct involvement in HIU meetings to escalate and address issues

• Review any new PSP’s as requested

• Act as change agent, promote HIU work in clinical practice and at all levels to enable self-management across MDT

• Ensure that the HIU service is high on the agenda of any specialty reviews in order that the senior ED team and medical directorate are informed of progress and the impact the service is having

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• Plan for a future workforce that may include a HIU Co-ordinator, using data gathered from the SHarED project

• Support and ensure the wellbeing of the HIU Co-ordinator; they may benefit from clinical supervision as this role can be pressured and intense

Other key stakeholders

• Senior medical and nursing team – it is important to gain commitment to project and be an advocate at all times

• Data analyst – providing monthly updates on HIU attendances

• Receptionists/Patient Flow Co-ordinators – need to be on board to flag up PSPs as patients arrive in ED so that they can be implemented promptly

• Administrative support

Link Matrons from the BRI For the SHarED project the ED Matrons from the BRI will oversee and support a system wide approach to the HIU management across the region. The Matrons have full and integral knowledge of how high risk the HIUs can be and the impact that has on not only the patient but also on the wider staff.

During the SHarED project the Link Matrons will offer support and advice regarding the setup of the HIU project in each trust as well as how to evaluate and provide continuous improvement. The Matrons will develop a plan to support their counterpart in other EDs by:

• Helping to identify resources required, including workforce.

• Support the HIU co-ordinator to develop workforce and business cases for longer term planning

• Governance supporting with PSPs and MDT meetings with aim of developing PSP

• Help promote counterpart embed HIU team In organisation

• Offer clinical supervision to other matrons and HIU teams in the region

• Give expert advice on any ongoing issues with developing the service

• Offer trouble shooting skills to others

• Continue to promote and spread the message of HIU

• Assist with cultural change


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A Day in the life of a HIU Co-ordinator

Arrive at work and log in to check emails. Respond to enquiries and any issues that have arisen since last at work

Check clinical alerts to see which high impact users have attended the Emergency Department over the last 24/48/72 hours

Check the notes of those that have attended to ensure that PSPs have been accessed and utilised if appropriate. Make a note of any new information that might be relevant to PSP e.g. changes in presentation/social situation/support

Attend the Emergency department/observation unit if any HIU’s are currently there. • Make sure staff have checked the alerts and are aware of the PSP• Speak with the service user, if appropriate, to discuss any recent attendances and offer

opportunity to discuss PSP

Head back to the office and check to see if there have been any new referrals.• Triage any new referrals to ascertain risk level• Allocate referrals to HIU coordinators for further investigation and work

Work on current caseload. On any given day this can include:• Researching patient notes to identify need and risks.• Writing to each HIU and their GP to invite their contribution to a PSP via questionnaire,

phone call or face to face meeting• Liaising with other professionals involved with the HIUs• Writing PSPs and discussing these with the team.• Reviewing PSPs annually (often before a year due to the evolving needs of service

users) and updating appropriately

Attend meetings, these can include:• Professionals meetings• Safeguarding meetings• Meetings with service users

Attend to any ongoing projects. These include data collection and quality improvement.

PATIENT LETTER

Insert Trust Header

PRIVATE AND CONFIDENTIAL Patient namePatient address

DATE:

Dear **patient name**,

D.O.B:Trust No: NHS No:

Frequent Attendance at **hospital name** Emergency Department

Attendance: **number** attendances in last year

We are committed to ensuring that patients access those health services that are best placed to meet their needs. Our records show that you are frequent attender to the **hospital name** Emergency Department. The Emergency Department’s role is to treat life threatening illness, acute injury and other urgent conditions that cannot be managed by the patients’ own GP or other community based service.

We have recently commenced upon an initiative, working with local GPs and the ambulance service to ensure that patients who frequently attend ED, with non-urgent conditions, are supported to access more appropriate services. There is evidence that inappropriate attendance at ED often does not address the underlying cause of a patient’s symptoms and can cause increased anxiety for patients and their families.

In light of your regular attendance at our ED, we would welcome your input into writing a personal support plan for you. We have enclosed a form with this letter which you can complete and return to us or, if you would prefer, you can contact one of our High Impact User team by calling us on **telephone number**. Your contribution to writing your support plan is encouraged as it enables us to provide you with the appropriate care should you attend the department in the future.

If you make the decision not to contribute to your support plan, a plan will be written in your absence. The plan will then be shared with you, for your comments.

We have also written to your GP to recommend that they meet with you to discuss your ongoing health requirements. We believe this is very much in your best interests and do hope you will take the opportunity to make an appointment with your GP at your earliest convenience.

Of course, should you need attention for a medical emergency, please do present to the Emergency Department.

Yours sincerely, Insert Names of HIU Team and Contact Details cc:

5.2 Patient information

PART 4 Resources

FORM FOR PATIENTS TO COMPLETE WITHOUT MENTAL HEALTH NEEDS

Insert Trust Header

FREQUENT ATTENDANCE AT **Insert Hospital** EMERGENCY DEPARTMENTThese are questions that you may wish to think about in relation to your personal support plan. Your replies to these questions will help us to form your support plan.

NAME:

Are there any risks of which the hospital needs to be immediately aware?

Under what circumstances, or with what problems, am I likely to attend the A&E Department?

What responses to my situation would I find most helpful?

What factors would indicate a higher/lower risk?

Do I need a specialist assessment? (Liaison Psychiatry, Drug or Alcohol Team, Homeless Health, or Domestic Violence Advisors)

If I have problems with my mental health, what circumstances/problems/presentations would suggest a mental health crisis or emergency?

Do I have any safeguarding issues?

If I attend the department due to a recurring health issue, what information would be beneficial for staff to have access to in my personal support plan?

Is there any additional information that I would like to give?

PART 4 Resources

FORM FOR PATIENTS TO COMPLETE WITH MENTAL HEALTH NEEDS

Insert Trust Header

FREQUENT ATTENDANCE AT **Insert Hospital** EMERGENCY DEPARTMENTThese are questions that you may wish to think about in relation to your personal support plan. Your replies to these questions will help us to form your support plan.

NAME:

Under what circumstances, or with what problems, am I likely to attend the A&E Department?

What responses to my situation would I find most helpful?

What factors or signs would suggest that I am becoming mentally unwell while in the department, or may mean that I am at risk?

Do I feel that I need to be assessed by the Psychiatric Liaison team each time I attend the department, if not, what do I feel would indicate that a psychiatric assessment is needed?

What circumstances/problems would suggest a psychiatric emergency?

When might I need to be referred to the crisis team?

PART 4 Resources

PATIENT LETTER FOR INSERTION WITH THE PERSONAL SUPPORT PLAN

Insert Trust Logo and Details

PRIVATE AND CONFIDENTIAL Patient namePatient address

DATE:

Dear **patient name**,

D.O.B: Trust No: NHS No:

Personal Support Plan, **hospital name**

Please find enclosed a copy of your personal support plan. An electronic copy exists that will be accessed by our staff if you present to the Emergency Department.

Please take the time to have a good look at the plan and contact us if you feel that there are any amendments that should be made by calling **telephone number**.

Of course, should you need attention for a medical emergency, please do present to the Emergency Department.

Yours sincerely,Insert HIU Team names and HIU team contact details

cc:

Date:

Review Date (minimum annually):

Name:

Telephone Number:

DOB:

Address:

Phone number:

Significant other/carer:

Risks:

Historical

Current

Under what circumstances or with what problems are you most likely to present requesting help?

What is the most appropriate response to the situation?

What factor/s would indicate a higher/lower risk?

Personal Support Plan Template

5.3 Documentation

PART 4 Resources

Do you need to be assessed by the Liaison Psychiatry team at every presentation (Y/N)?

If not, what would indicate assessment is required?

What circumstances/problems/presentation would suggest a psychiatric emergency (therefore requiring referral to the Crisis Team)?

Any action plan?

Any additional Patient/GP/care co-ordinator information?

Please give details of professionals/others involved, e.g. GP, CPN, care co-ordinator, carer etc.

Name Role Contact number Copy Sent To (Y/N)?

Do not want information shared with:

Completed by:

Verified by:

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ICECAP-A Questionnaire

ICECAP-A Instructions for use

Quality of Life Measure: ICECAP-AThere are several types of ICECAP measures for capability and quality of life: • ICECAP-A: a measure of capability for the adult population• ICECAP-O: a measure of capability for the older person• CES – Carer Experience Scale: a measure of care related wellbeing• ICECAP-SCM: a measure of capability for use in end of life care (Under development)

For further information on ICECAP, visit the Birmingham University website.

ICECAP-A in the SHarED ProjectFor the SHarED Project, we are using ICECAP-A (link to) for the selected High Impact Users in each adopting trust.

ICECAP-A is a measure of capability for the general adult population for use in economic evaluation. It focuses on well-being in a broader sense rather than health. The measure covers attributes of wellbeing that were found to be important to adults in the UK.

ICECAP A is made up of 5 attributes: 1. Stability – an ability to feel settled and secure2. Attachment – an ability to have love, friendship and support3. Autonomy – an ability to be independent4. Achievement – an ability to achieve and progress in life5. Enjoyment – an ability to experience enjoyment and pleasure

A questionnaire can be completed prior to implementing the Personal Support Plan and then repeated at six months.

We recognise that not all HIU patients will want to complete one but the added narrative gathered will provide a user insight into the project and the service offered.

Interpretation of ResultsEach question is marked out 1-4, the higher the score the better the quality of life/capability. It is hypothesised that, through the implementation of a Personal Support Plan, the SHarED project will increase a patients individual scores.

The accumulated score is represented by coding. For example, ‘44444’ represents the state described by full capability on all 5 attributes. 44144 represents the state described by no capability on the autonomy attribute, but full capability on stability, attachment, achievement, enjoyment.

Data CollectionThe flow chart on the next page summarises the process for using the ICECAP-A questionnaire.

In the SHarED Data Collection Dashboard, the results of the survey can be inputted in to the “ICECAP-A” tab. The pre-plan score and 6 months post-plan score will be analysed for improvement.

Storage of ResultsIt is recommended that the questionnaire is stored in the patient notes.

Process for Data Gathering and Recording

1. Identify High Impact Users

2. Complete pre-plan questionnaire

3. Input data

4. Complete post-plan questionnaire

5. Data collection

• Identify High Impact Users (HIUs)

• Complete the ICECAP-A questionnaire with HIUs opportunistically when patient presents• This may be completed at the same time as contacting the patient to co-develop the plan

(as appropriate)

• Input the results in to the ‘ICECAP-A’ tab in the SHarED Trust Data Dashboard• Record the date the questionnaire was completed. The follow up date will be calculated

and auto-populated• If it is not appropriate to complete the questionnaire with individuals, select ‘N/A’ in the

drop down box and provide any reasons in the comments section• If the patient has declined, select ‘Declined’

• 6 months post completion of the PSP, call the HIUs who completed the pre-PSP questionnaire. If the patient attends at around this time, the questionnaire could be completed face-to-face

• If you are not able to complete this over the phone, or face-to-face send the questionnaire to the patient using the pre-prepared envelope provided by the West of England AHSN (containing the questionnaire, supporting letter and pre-stamped return envelope)

• Input the results in to the dashboard

• The West of England AHSN will analyse the results at the end of the project


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Trust logo

Contact details

DateDear xxx,

As you are aware, the High Impact User Service in the Emergency Department of **insert hospital** has developed a Personal Support Plan to make sure that you are well supported, both inside and outside of the hospital.

Before the plan was put in place you kindly completed a questionnaire about your Quality of Life. The plan has now been in place for six months and it would be very much appreciated if you could recomplete this questionnaire. This will help us to understand if this plan has benefitted you.

We have enclosed the questionnaire for you to complete and return to us using the pre-paid enveloped. Please make sure that you fill out your name and the date completed, as well as answering all questions.

Many thanks in advance for completing this.

Yours sincerely

xxx

ICECAP-A Patient follow-up letter

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5.4 High Impact User Multi-Disciplinary Team Resources

1. General Purpose 2.1 To identify people presenting as High Impact Users to the emergency department.

2.2 To identify the causes of frequent attendance to the Emergency Department. 2.3 To inform staff and address these needs through the formulation of a Personal Support Plan (PSP) for use in the Emergency Department. 2.4 To monitor and update existing PSP as required/annually. 2.5 To liaise with other specialist teams and organisations to formulate support plans for High Impact Users. Membership 3.1 The core membership is:

• ED Consultant• ED Matron(s)• High Impact User Coordinator(s)• HIU administrator

3.2 Other colleagues from supporting/associated organisations will be invited to contribute where appropriate and with their agreement. Please see appendix 1 below for a list of potential stakeholders to the HIU team.

3.3 High Impact User Meetings will be held once a month. 3.4 Meetings will be held to provide updates and discussion about a set list of High Impact Users 3.5 The agenda for the meeting will be written in advance by High Impact User Coordinator. Minutes will be taken and shared with participants after each meeting. 3.6 Meetings may be held more frequently if deemed appropriate. Structure 4.1 High Impact user will be identified via number of attendances list or referral from self or MDT. 4.2 Patents will be Triaged using toolkit to assess priority of PSP formulation 4.3 Thorough check of records and notes available. 4.4 Letter sent to service user to inform of process and invite contribution to PSP by means of questionnaire or meeting. 4.5 Letter sent to GP to invite contribution. 4.6 Liaison with internal and external teams to identify needs and solutions. 4.7 Creation of PSP. 4.8 Creation of Verification of PSP by other members of immediate team. 4.9 PSP uploaded to medical record and Connecting Care to be accessed by staff in the Emergency Department as appropriate. 4.10 PSP shared with service user via letter or meeting. 4.11 Please note PSPs can be created without seeking input from the patient if the patient lacks capacity, or there are safety concerns.

HIU Project Group Terms of Reference

2.

3.

4.

These terms of reference set out the purpose, membership and responsibilities of the High Impact User team


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GP QUESTIONNAIRE TEMPLATE FOR COMPLETION

Insert Trust Header

FREQUENT ATTENDANCE AT **Insert Hospital** EMERGENCY DEPARTMENT

Please complete the relevant information below and return to:

**Insert Address*

Patient Details:

GP Details (amend if incorrect):

(1) Main diagnosis/situation leading to attendances:

(2) Relevant support and frequency of it:

(3) Current community plan for the patient (if any)

Signed: Print Name: Date:


55

GP LETTER AND PROFORMA

Insert Trust Header

PRIVATE AND CONFIDENTIALGP NamePractice NamePractice Address

DATE

Frequent Attendance at **hospital name**

Dear **Dr GP Name**

Re: Patient namePatient DOBPatient AddressTrust NumberNHS Number

This patient has attended on various occasions: **number attendances** this year

In line with national guidance, the Emergency Department (ED) at **trust name** has been working with local GPs and South West Ambulance Service to improve the care of patients who attend the ED frequently.

This patient has been identified as a frequent attender to **hospital name**. Recurrent attendance at an ED often increases patients’ anxiety and reduces their independence.

You may already know this patient well, but we would be most grateful if you would review them to see if there is any way in which you can improve their health needs and alter their health seeking behaviour. Writing and sharing a Care Plan with staff at ED, Ambulance Services and Out of Hours services can significantly improve the care of these patients.

…cont’d…

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…cont’d…

Please send copies of their Care Plan to:NameAddress

Actions for GPIn your Care Plan, please consider including important clinical measurements e.g. O2 sats in COPD; social support e.g. carers and NOK details; other important professionals involved in their care e.g. social worker, CPN, Crisis Team; in addition to a management plan.

We would also value any information you are able to provide about attendances to other hospitals.

Alternatively, please complete and return the enclosed form in order that we can draw up a Care Plan for this patient.

You are welcome to discuss this patient’s attendances with an ED Consultant, to help to develop a robust Care Plan which can be used and supported across the system. Please telephone **telephone number** and this can be arranged.

Thank you for your help in assisting us to improve the care of Frequent Attenders at **hospital name**

Yours sincerely,

xxx


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5.5 Pathway mapping

Data gatheringBelow is an example of the coding you may want to use to find your first HIUs to start working with. This has been coded using the parameters below; you may wish to adjust these as your service develops.

Data for the last 12 months for patients who:• Have attended the emergency department 5 times or more in the last 12 months

with their last attendance within the last 3 months• From the sample generated, select the top 20 only.

An example of the coding you may want to share with your Business Intelligence Team to find your first HIUs is available at weahsn.net/shared

System alertsIt is important that alerts are set up on your systems to inform staff that patients have a PSP in place. Additionally, if the HIU co-ordinators are available when a HIU attends the ED, it is useful for them to be alerted so that they can assist the ED staff. Therefore, an alert email informing them of their attendance is useful. The instructions below explain how alerts are set up on the systems at UH Bristol. Please note that this is for Medway only and processes are likely to differ depending on the local systems.

How to add a frequent attender alert on Medway

1. Access patient record on Medway2. Go to patient home page3. Click “Menu”, select “Alerts”4. Click to “ Add Alert”5. Complete alert information as below6. Click to create alert to complete Medway alert.

How to add a frequent attender alert on My Clinical Portal

1. Log into My Clinical Portal through Connect link2. Click “UHBristol – Clinical Alert Service”3. Click “Manage Patient Lists” 4. Select appropriate Alert from drop down menu5. Click “Add New Patient”6. Enter patient NHS number of Trust number as appropriate7. Review patient to details to ensure accuracy8. Click “Confirm” next to patient details9. Patient has been added to My Clinical Portal Alert.


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Complex HIU Timeline of Events and Milestones

History of attendances:2010 2 attendances2012 3 attendances2013 7 attendances2014 3 attendances2015 3 attendances2016 9 attendances2017 32 attendances2018 40 attendances2019 12 attendances

First PSP written and published

January 2018

• Professionals meeting held to discuss PSP

• PSP updated

March 2018

• Complaint meeting with patient

• Debrief for staff following complaint meeting

May 2018

February 2018

• Safeguarding meeting held following concerns raised by Ambulance service

• Personal support plan (PSP) updated

April 2018

• Unacceptable behaviour letter sent to patient following aggression towards ED staff

• Complaint received from patient

• PSP updatedHighlighted as a high impact user and initial letter sent

November 2017

PSP updated

August 2018

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PSP updated

December 2018

Catch up telephone call between ED consultant and Patient’s GP to discuss complaint meeting

September 2018

• Meeting held to present and explain PSP and expectations of care

• Complaint meeting

March 2019

PSP updated

August 2018

Many phone calls held between ED consultant/ED matrons and Patient’s GP to discuss care and ED attendances over a period of several months

August - October 2018

112 calls made by patient to Ambulance service

January - November 2018

PSP updated to current status

April 2019Professionals meeting held to discuss joined up PSP and multidisciplinary management

November 2018

Complaint received from patient

February 2019


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5.6 Training“Bitesize training” sessions are to be delivered in the Emergency Departments to all ED staff during their shifts. The training focuses on:• What a HIU is and the risks of being a HIU • The role of the team• How staff refer to the service• How to access PSPs

These sessions have proven to be vital to the success of the team and result in staff flagging up patients early. They are also pivotal in promoting a positive culture around HIUs throughout the department. It is for this reason that it is recommended that all staff in all roles should be trained, including the administrative teams.

In the BRI, hour long sessions are also delivered to Emergency Nurse Practitioners and medical staff, including junior doctors to ensure that they are considering the PSPs from early on in their careers and as part of their teaching rota. Understanding the characteristics of the HIUs and their health needs might help support the preventative interventions required for this group, reducing harm, increasing quality care whilst attempting to reduce associated costs associated.

A template for the “bitesize” ward training session can be found online on the West of England AHSN website. This is designed to be adapted to the local set-up.

5.7 Communications

Communications plan

It is important that a communications plan is developed prior to launching the HIU Service in order to boost awareness of the project within the local department, throughout the trust and also to any other members of the wider MDT (including but not limited to the local mental health trust, ambulance trust and third sector).

We recommend discussing this with your trust communications team.

The resources created for the SHarED project, as seen in this toolkit, can be used as templates and adjusted for local purposes.

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Example email to ED Staff for launch of service

Below is a draft email for launching the service within the local emergency department.

Dear colleagues,

It is with great pleasure that we can announce the launch of the pilot High Impact User (HIU) Service in our Emergency Department. **Insert Name** will be working one day per week, newly appointed, HIU Co-ordinator, supported by **Insert Name** as the HIU Clinical Lead.

We have been working alongside the team at the Bristol Royal Infirmary and the West of England Academic Health Science Network (who are funding the pilot of the HIU co-ordinator) to implement this service.

The aim of the project is to assist you in managing our HIUs; to support patients to reduce their attendances and admissions and as consequently boost staff morale. Personal Support Plans (PSPs) will be written by xxx and relevant members of the multi-disciplinary team and placed on the clinical record system, accompanied by an alert.

Please keep an eye out for the PSPs and review them prior to seeing patients. They are there as a guide to help manage these individuals.

Moving forward **Insert HIU Co-ordinator name** will be starting to triage and prioritise a small number of patients who are already recognised as a HIUs, however please contact xxx to discuss any other potential referrals. Training for this service will be delivered in due course, but please contact **Insert HIU Co-ordinator name** if you have any immediate questions.

We welcome your feedback, particularly in this early stage, and will keep you updated on the progress that we are making.

Kind regards, xxx xxx xxx Emergency Department HIU-Coordinator Emergency Department HIU Clinical Lead

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To support successful implementation of this project, posters and infographics have been developed. One of these posters is shown in this toolkit, however all are available online at www.weahsn.net/shared

Additionally, pens and notepads have been provided by the West of England AHSN as aide memoires.

Posters and aide memoires

Have you seen a patient who frequently attends the Emergency Department?

Is the Emergency Department the best place to care for them? Speak to the High Impact User Team. The patient may benefit from specialist review and a Personal Support Plan.

How do you reach us? Tel: ________________________

Email: ______________________


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5.8 Checklists for implementationGet Ready For SHarED Set Up Checklist

1. Knowledge and understanding of the current local HiU data. 2. Awareness of the current management of HIUs. 3. Identify key local stakeholders for the project:

• ED Consultant • ED Clinical Director • ED Matron • Executive sponsor of SHarED project • Drug Nurses • Alcohol Nurses • Psychiatry liasion

4. Review and consider local challenges and factors for success. 5. Identify key roles at local level: ED Consultant, ED Matron, HIU

Co-ordinator.

6. Develop project delivery plan at local level with start and finish dates for each unit (use of the example project delivery timeline).

7. Develop a communications plan for local implementation. 8. Agree local triaging tool and prioritisation process. 9. Develop all documentation:

• Personal Support Plan • Patient Letter and questionnaire • GP letter and questionnaire • Multi-disciplinary Terms of Reference

10. Agree governance process for Personal Support Plan ‘sign off’. 11. Agree communication plan with the trust Communications Team. 12. Clarify process for placing alerts on the Clinical Record System. 13. Design a training plan for the Emergency Department Staff. 14. Develop the training resources. 15. Agree a data review process is in place: Who? How frequently? 16. Consider the long term sustainability of the HIU team.

SHarED Launch Checklist Done

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SHarED Launch Checklist

Determine launch date with Project Team. Ensure this does not clash with other department events/Trust initiatives.

Week prior to Launch

Email staff to inform of launch (see draft email in communications section) Meet with Trust communications team to place a short article in Trust newsletter

Print posters ready for launch day

Week 1 Day of Launch

Ensure HIU Service posters are up in key staff areas. Email all ED staff about the new initiative: what it is, what it sets out to do, what they need to do, how they contact the HIU Lead/team, how to refer patients.

Discuss with senior nurses to ensure they are aware of the process and requests that they encourage juniors on shift to refer to the service.

Clinical Lead to send out Culture Survey to all staff. Start to triage first six patients. Use the EDITT tool (PDSA 1) as well as using your own modified tool (PDSA 2) and compare the results.

Week 2

Rotate posters; replacing with a different style in each area to maintain profile.

Email all ED staff with an update of progress from Week 1.

Report progress to Project Team.

Commence work with selected HIUs.

Week 3

Rotate posters; replacing with a different style in each area to maintain profile. Email all ED staff with an update of progress from Weeks 1 and 2.

Week 4

Repeat Week 3.

Report progress to Project Team.

SHarED Launch Checklist Done

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PART 6 Reporting, sustainability and evaluation

ED Emergency DepartmentENP Emergency Nurse PractitionerHIU High Impact UserMDT Multidisciplinary Team PSP Personal Support PlanSHarED Supporting High impact users in Emergency Departments

PART 6Glossary and abbreviations

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www.weahsn.net/shared

a implementation€¦ · this shared quality improvement toolkit was originally created in march...

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