Reducing hospital admissions

Improving care for people with dementia

QIPP Principles

Whole health and social care economies

Teams include patients, social care, community services, AHP’s, general practices and secondary care clinicians

20% reduction in unscheduled admissions 25% reduction in length of stay

Reduction in readmission within 30 days

Cornwall background

The prevalence of dementia increases markedly with age and in the UK it is estimated that some 750,000 people have dementia. In Cornwall public health epidemiological data suggests anticipated prevalence of dementia is 8536 however only 3752 of people with dementia recorded on GP QOF registers (March -11).

Care homes admissions RCHT

Total number of admissions 2009: 1654 Total number of admissions 2010: 1856

999 calls Jan 2011 227

More than 4 campaign

Identify reasons for admissions, Training needs analysis Implement training Join up systems and intelligence, Enhance and improve patient care.

Impact on clinical quality•Joined up intelligence •Educated and supported workforce•Develop what to do if flow chart for common conditions.•Awareness of disease pathology•When to call the GP•Simple nursing care procedures•Improved patient care in the right place at the right time•Safe and appropriate care to meet individual needs•Reduction inappropriate prescribing•Reduction anti psychotics•Reduction in falls•Tele-health implementation•Better end of life care•Better pain control and assessment.•Access to specialist clinicians and services:

More than 4

Nursing care home admissions audit Monthly Case note review more than 4 admissions Data collection End of life dementia pilot Care home survey Amp Tele-health

Care home questionnaire

The rationale for a countywide care home questionnaire and a review of services, was to report ‘thematically’ on the effectiveness of the current services, potential gaps and suggest improvements from the care home staff perspective.

  The review made use of 30-minute telephone interviews with

care home professionals (n=27) from high and low admitting care homes.

Common themes Low admitting care homes:

•1-2 GP Practice per home•Regular ward rounds and review (many on a weekly basis).•Combination of RMN and RGN nursing staff District nurse in-reach

 Support to care homes can be split into three main areas

Medical and pharmacist support Community service support Training and education

Support (continued)

Service directory for care homes 1-2 (max) GP practice per care home End of life pathway for dementiaDementia training for some GPs especially medication management District nurse and /or Community matron input and support Someone to call just to talk things through rather than call 999 Serco first, Responsive community mental health teams.

Care home audit 2009

Aim Audit : To identify the numbers of patients admitted from nursing homes with a view to:

1. Identifying the appropriateness of admission i.e. those requiring acute care (whether there is an alternative to admission to hospital).

2. Determining a care pathway to prevent unnecessary admission

3. Facilitating the patient illness journey in the best setting for the individual.

4. Considering the potential cost implications of inappropriate acute admissions of people with dementia

Methodology

A case note audit of patients with known diagnosis of dementia admitted into an acute district hospital (Royal Cornwall Hospital) from registered nursing care homes in Cornwall.

The patient cohort identified using monthly admission figures provided by the NHSCIO

Review of medical records in conjunction with a written proforma.

Key areas for scrutiny included:

1. Source of referral i.e. A&E or via GP2. Involvement of GP prior to admission3. Hour of admission4. Reason for admission / Diagnoses5. Length of stay6. Place of discharge (final outcome)7. Alternative treatment options8. Cost implications around end of life care and

admissions

Results

n221 case notes were reviewed The total number of admissions from nursing homes

to Royal Cornwall Hospital during 2009 was 534. Only those with a known diagnosis of dementia were

included. Exclusions included those attending Accident and

Emergency Dept. but not admitted, and those attending for elective surgery.

The median age for participants was 81 (range 54-104).

Source of Referrals

The number of patients referred by GP was 90 (41%), 131 (59%) were

admitted via emergency 999 service;

Pie Chart: GP Direct Admissions verses 999 Emergencies

41% (GP)

59% (999)

Break down of 999 emergency admissions

999 emergency admissions subdivided into those within and those out of standard working hours n131

70

28

6 *27*

(Admission appropriate *)

Outwith working hours 1800-

within working hours 0800-1800hrs

999 admissions

131 were admitted via 999 paramedic/ambulance services.

28 were appropriate (103 alternative options to hospital admission could have been offered.

97 admitted during standard working hours In total study (n221); 71 were admitted for end of life

care (palliative) of whom 59 (83%) were admitted via 999 services and 19 patients (27%) were admitted out of standard working hours.

GP Involvement

54% required acute care.

54

36

0

10

20

30

40

50

60

per

cen

t %

AppropriateAlternatives

available

GP admissions

Percentage of GP Admisions that required Acute Care

Reasons for Admission to RCH

Medical Conditions Number of patients (n221)

Percentage%

Infection LRTIUTIOther(ulcers/gangrene, meningitis)

39 

2397

17.6

Falls FractureNo fracture

30 

1614

13.6

Cardiac (MI,ACS,AF,CCF) 16 7.3

Stroke 14 6.3

Breathlessness and fatigue 11 5.2

The majority of admissions were via medicine (n195 ; 90%), the rest were a mixture of orthopaedics (n11 ; 4%) and surgery (n15 ;6%).

59% (n130) patients who were admitted to RCHT during this 11 month period did not require acute care –98 (44%) admitted via 999 services.

8 (7%) required step up care and 71 (57%) were palliative, therefore there were 41 other individuals who may have received care at home thus avoiding admission 28 of whom were 999 admissions.

Final Outcome (Discharge or Death).

 

70% of patients were discharged back to their

original nursing home, 4% were discharged to a step up

care and 26% died in hospital.

Pie Chart: Final Outcome for Patient Journey.

70% Back to NH

26% Died in Hospital

4% Step Up

Outcomes and Alternative Options

Alternative treatment option

Number of patients

Antibiotics 25

Intravenous fluids 4

Bowel /bladder care 4

Pain management 7

Stroke/TIA (in severe dementia) –no intervention

4

Falls prevention 10

End of Life care plan 67

Step up –place direct from community

9

Total 130 (59%)

End of Life Care

In relation to those patients with advanced terminal phase dementia, 71 (32%) were palliative.

Died in Hospital 58

(81 % of EoL subgroup)

Transferred back to Home 13

(19% of EoL subgroup)

EoL Costing ( based of non elective national tariff)

Total £143485 (over 11 months) (Mean £124504) Mean cost per person admitted for Eol care £1486.24

(£2020.92 +cc).

The above is based on PbR Tariff for 2010-11 – these figures were used to help quantify costing in real time.

Implications for Practice and Recommendations

Identifying End stage Dementia

There is a clear need to identify those with advanced terminal dementia within their care setting and instigate plans for care that are anticipatory, respectful of best interest and advocacy, appropriate to meet the needs of the individual client.

End of Life Planning

End of life planning / care pathways prevent unnecessary admission to acute care and enhance the delivery of palliative care for this client group in the care home setting.

End stage dementia Pilot

What is End stage dementia End of life dementia pilot Education to staff and carers Pathway Best Interest document

(front notes flag to Oohrs)

Allow a natural death

Response so far

Over 300 patients 7 x care homes All GPs signed up Out of hours 999 Relatives feedback positive People dying in own care home and less admissions

before death

?