Demand management: home help

Demand management is a particular focus for the NHS post Five-year forward view. The enhancement of community and primary care services, together with the integration of health and social care, provide the policy backdrop for tackling demand, but can groups of people be given greater support to avoid hospital admission?

Older people, particularly in care homes, where the residents are frail and often have a number of complex physical and mental needs, are among the most frequent users of healthcare. NHS England says one in seven people aged over 85 now live in care homes and there is evidence their needs are not being properly assessed or addressed, leading to unnecessary unplanned, avoidable admissions to hospital.

To help tackle this, the NHS in England set up its Enhanced health in care homes (EHCH) vanguard to look at ways of reducing the demand.

Six areas were selected to take part in the EHCH programme, which, along with the other elements of the three-year vanguard programme, was completed at the end of March. As well as testing the impact of various interventions, the sites have helped develop a framework that describes the EHCH model and how it can be commissioned.

The framework comprises seven fundamental elements:

• Enhanced primary care support
• Multidisciplinary team support
• Reablement and rehabilitation
• High-quality end-of-life and dementia care
• Joined-up commissioning
• Workforce development
• Better use of data and technology.

The six sites built on already established local engagement with care homes. South London’s Sutton Homes of Care vanguard, for example, developed a range of initiatives. These included: multidisciplinary teams to improve the outcomes for patients with complex conditions, with a view to identifying potential health issues early; training packages for care home staff; and a tool for identifying the early signs of dementia.

The Sutton vanguard also developed the ‘red bag’ scheme – a simple idea, now adopted by many areas – to ease the transfer into and out of hospital. The bag contains information about the resident’s health and includes standard information about health problems and medication they are taking. When they go home, the resident takes their discharge summary in the bag, so care home workers have the details on discharge.

Airedale collaboration

The biggest EHCH vanguard in terms of footprint was in West Yorkshire and East Lancashire. Known as Airedale and partners, the collaboration involved three trusts including Airedale NHS Foundation Trust, local CCGs – covering Airedale, Wharfedale and Craven, Bradford and East Lancashire – as well as community and mental health providers, social care and voluntary organisations.

Rachel Binks, a nurse consultant in digital and acute care at Airedale NHS Foundation Trust, and clinical lead for the vanguard, says much of the initial work was based on its successful telemedicine service.

As well as introducing other ideas to improve services to care home residents, the vanguard tested the application of 24-hour video-based care and assessment.

The trust established its telemedicine service in 2007 and offers video consultations in prisons (more than 1,000 consultations across the UK each year) and supports 25,000 care home residents.

Initially, the telemedicine service was based solely around patients with long-term conditions, such as diabetes and heart failure, in their own homes. However, in 2011 the service expanded into care homes as this is economically more viable. Instead of a single installation of equipment for one patient, in care homes a single installation could serve 50 or more residents.

‘We were struggling to get a critical mass of clients to provide enough funding to keep our telemedicine hub staffed 24 hours a day. So we went into a joint venture in 2013 with Involve VC to provide the expertise on installation, IT support and managing relationships with the care homes, while we provide the clinical service.’

Overall, the trust is contracted by 26 CCGs to offer telemedicine in around 600 care homes across the country. Around half of the homes were directly involved in the EHCH vanguard. When the vanguard started, around 120 care homes were involved, but that doubled in the first year to around 250, before rising nationally to around 300.

Ms Binks says that if a resident or care home staff have any concerns, they can call the telemedicine hub 24 hours a day. A nurse or paramedic assesses the situation and takes appropriate action – this could range from answering a question, requesting a local GP or community nurse visit the resident, or even calling an ambulance.

But the telemedicine element of the vanguard looked beyond the video assessments – also providing remote training and virtual supervision to care home staff. This reduced demands on GPs and community staff – for example, by supervising care home staff to give fluids or paracetamol.

Ms Binks says: ‘This might offset some of the pressure falling on GPs or hospitals. We want to enhance the knowledge and abilities of care home staff and make sure we are not thinking differently about residents just because they are in a care home – we should avoid the need to admit them to hospital, just as we would if they lived in their own house.’

A&E impact

An assessment by the Yorkshire Health Economics Consortium, published in March, found reductions in A&E activity (-0.3%), 111 calls (-4%) and inpatient emergency (-3%) in care homes with telemedicine compared with the period before installation. There was a 2% increase in the use of GP out-of-hours services.

By comparison, in a small control group of homes without telemedicine, 111 activity rose 36%; A&E 30%; inpatient emergency activity 7%; and out-of-hours GP activity by 56%.

However, the York team urged caution on these findings – it said there were issues over statistical significance, given the sample size of some of the comparator groups, for example. It warned that the results can only be seen as indicative.

Ms Binks says the impact of the vanguard varied, depending on the attitudes of care home staff and local GPs, levels of frailty of residents and the previous degree of support and engagement from community services.

But she believes telemedicine in care homes can make a big difference, working alongside other support schemes. In East Lancashire, for example, there has been a huge focus on telemedicine as part of the vanguard, together with enhancing community services to care homes, and there have been reductions in A&E attendances, ambulance calls, hospital admissions and GP visits.

‘We have learnt that if the local support to care homes is really good, we can make it fantastic, as we can enhance existing services rather than replacing them. But clinical engagement and support from GPs, community teams and the care home staff are hugely important as we need the GPs and community teams to be going into the homes to talk to the residents about what they want in their plan of care.’

The Airedale vanguard is working closely with colleagues in the nearby Wakefield vanguard on telemedicine, providing the service to a small number of care homes.

Multidisciplinary effort

The Wakefield vanguard, known as Connecting Care, is itself focused on developing a multidisciplinary team (MDT) to look at physical and mental health of individuals.

The team included colleagues seconded from local acute and mental health trusts. They reviewed care plans for individuals and co-ordinated with a community geriatrician to see if a comprehensive geriatric assessment was needed.

‘It is very much person centred,’ says Connecting Care senior project manager Lesley Carver. ‘Ultimately, the question we wanted to ask ourselves was: “Would I want my mum and dad in that care home?”. We wanted to be able to say: “Yes, we would”.’

The MDT includes a general nurse, mental health nurse and physiotherapist, while a GP care home lead works with the 26 practices aligned with the vanguard care homes. Wherever possible, the GP ensures one-to-one mapping of GP practices to care homes. They also provide a regular, scheduled visit to each home to support medicines reviews, end-of-life planning and dialogue with carers and families.

Wakefield Clinical Commissioning Group, which led the vanguard, says: ‘When a resident moves into a care home, a holistic approach to assessment is undertaken as part of care planning. This should recognise frailty and include an assessment of functional needs and both physical and mental health.

‘Assessment and care planning is an iterative process, which includes reviews at the six-month time period. When a resident moves between a care home and hospital, a prompt and efficient transfer of clinical care is supported.’

Ms Carver believes the MDTs have been important in building a rapport with care home managers.

‘They see the team coming in on a regular basis and staff feel confident to bring up any issues they might have,’ she says. ‘It also encourages them to train – we may have some training around dementia and end-of-life issues. This provides a better quality of life for residents, helps minimise the falls and upskills the staff as well.’

She adds that there have been some encouraging signs. In June 2017, a year-long evaluation found a 13% reduction in emergency admissions in the Wakefield vanguard care homes, compared with a control group of residents in the care homes not in the pilot. In addition, A&E attendances were down by 6% and ambulance call-outs down 5%. There was a reduction in bed days by 28%.

‘Long-term conditions and falls management have improved in care homes,’ says Ms Carver. ‘We’ve seen improvement in end-of-life care, with people able to die where they choose, proactive care management and care planning. We are starting to see a lot of benefits.’

The savings in 2016/17 were about £1.65m, with costs of £959,000, resulting in £688,000 of net savings. The vanguard received £550,000 from NHS England in 2016/17 and £405,000 in 2017/18.

Funding has been important for the EHCH vanguards. The Airedale and partners vanguard received £1.5m in the first year, then £500,000 in the second. In the third year, a further £500,000 was available if the CCGs signed up to the EHCH framework – only the East Lancashire CCG was in a position to do so.

‘The funding made a big difference in getting the technology and the framework embedded,’ Airedale’s Ms Binks says.

Telemedicine focus

With the vanguard – and the separate funding – now ended, the localities are looking to focus the use of telemedicine on where it will make the biggest impact. Ms Binks says that some homes did not use the technology effectively, while others did not need to use it as frequently – for example, if they were well managed with good community support and staffed by registered nurses.

In Wakefield, Ms Carver says: ‘The vanguard will help lay the groundwork for the STP and integrated care system. Though the funding finished on 31 March, it becomes business as usual for us.’

To this end, the CCG has set aside just over £900,000 to fund the services in 2018/19 and has selected a further eight care homes to continue the trial of the Airedale telemedicine system from the end of this month.

Using GPs and other clinicians, often as part of MDTs, to reduce the transfer of care home residents to hospital is not unique to the EHCH vanguard areas. A pilot in Barking and Dagenham, Havering and Redbridge CCGs that gave GP support to four nursing homes led to a 36% reduction in emergency admissions to hospital. A study of the Health 1000 pilot by the Nuffield Trust found that the largest reductions in admissions were during the last three months of life.

The scheme offers nursing homes access to GPs between 8am and 8pm, seven days a week, together with training and advice and support from a geriatrician. Staff told researchers that they felt more supported and able to get advice quickly, when previously they would have sent a resident to A&E.

The report estimates that the monetary value of the reduction in emergency admissions could lead to savings of £1,000 per patient per year, although this would not necessarily translate to direct savings for commissioners or providers.

Nuffield Trust senior research analyst Chris Sherlaw-Johnson says: ‘It is encouraging to have found a service that appears to show real benefits for nursing home residents and staff. This research shows how primary care may be able to take the burden off local hospitals as well as offering better quality of care in a more comfortable environment.’

But he adds: ‘We don’t know about the sustainability of these findings in the longer term and organisations wanting to replicate the service in their own area must note that success relies on building and maintaining effective relationships between staff and GPs.’

This appears to be one of the major learning points from the vanguards too – initiatives such as telemedicine or assigning a GP or multidisciplinary team to individual care homes can make a difference. But the key to success is the engagement and support of all local clinicians and care home staff.