Safely Reducing Avoidable Conveyance Programme

Emergency Care Practitioner (ECP) / Specialist Paramedic (SP) Care Home Scheme

Brief Description of Initiative

Many 999 calls come from care and nursing homes where there is a need for a rapid assessment of a patient, which the Care Home staff are not always clinically qualified to deliver. On arrival, the ECP / SP (Urgent Care) will discuss their clinical assessment of the patient and a joint decision between EEAST and the Care Home staff will be made as to the best course of action for the patient. Historically, a Double Staffed Ambulance (DSA) crew in similar circumstances would often primarily convey the patient to ED. Many patients can however be left in the care of the home until the next day with a temporary care package, until the patient can be assessed more appropriately by the GP. ECPs / SPs can often prescribe medications such as antibiotics for UTIs, etc, negating the need for any further intervention at all.

In addition, we learn where there are problems with individual Care Home providers to cope with the health needs of their clients. In essence, the ECPs / SPs become EEAST’s Care Home liaison officers across the CCG footprint. This liaison works with individual homes to deliver training, awareness and support to prevent further calls to the ambulance service. If delivered at scale, this would provide an enhanced 999-call avoidance scheme to supplement other community based admission avoidance schemes.

Date Initiative was introduced in Trust

The schemes initially started as a pilot in 2016 and was subsequently rolled forward on an annual basis. As of April 2019 the scheme has been commissioned for three years with the option to extend for a further two years.

Date of upload or review

Uploaded to Repository 1st January 2020.

Background Context

Care Homes often present as frequent callers to urgent and emergency healthcare services and often, this is due to a lack of available primary care services in their locality. Predominantly, the top five clinical reasons for admission from Care Homes are identified as lower acuity presentations:

  • Urinary Tract Infections (UTI)
  • Chest Infections
  • Syncope
  • Falls
  • Wounds / Bleeds

The ECPs / SPs offer bespoke training programmes to Care Homes to further support their own low-level patient interventions and educate them on what Health and Social care services are available, and when it is appropriate to use them. The education programme offers:

  • Ability of Care Home staff to manage patient presentations / acuity themselves
  • Improved competency of the Care Home workforce
  • More appropriate use of healthcare services and alternative care pathways where available
Which specific patient group or presenting need is this response targeted at?

The frail elderly residing in Residential and Nursing Homes.

Geographical area or location covered by this response model

West Hertfordshire (Herts Valleys CCG footprint).

Key Aims

Patients within the Nursing or Care Home system are, in most cases, permanently resident within those establishments. In effect, these are their normal places of residence. It is never beneficial to move a patient from their home unless it is wholly medically appropriate. In the case of many Care Homes, patients are conveyed to hospital because there is insufficient care available at the right level to keep them there.

Often, ambulance crews have no choice but to transport patients to hospital as this is the only alternative as a place of safety. The Nursing and Residential Home Admission Avoidance service is designed to leave the patient within the environment that they know and trust, wherever possible, with appropriate safety nets in place.

Benefits for Patients

In addition to the demonstrated system benefits below, a reduction in acute hospital admissions protects patients against:

  • Hospital acquired infections
  • Disorientation
  • Separation from friends, family and carers
  • Breaking of established comfortable routines and surroundings (especially for Dementia patients)
  • A tendency to relinquish responsibility for own well-being (i.e. remaining off their feet / reduced mobility)
Benefits for Trust or System

As an admission avoidance scheme this provides significant system benefit. The patient does not attend ED unnecessarily and so by default, is not admitted when they could have been left safety-netted within the community.

Importantly, for the Health and Social care system, application of ECPs / SPs as Care Home Liaison Officers will also highlight particular establishments that require additional support to safely manage their client group without the need for excessive and unnecessary access to urgent and emergency care services.

  • Reduction in ambulance conveyance to A&E from Care Homes
  • Reduction in unplanned admissions of Care Home patients
  • Reduction in known frequent use of the urgent and emergency service
  • Improved education, experience and support for Care Homes
Implementation

1.      How long has this initiative been operational?

The schemes initially started as a pilot in 2016 and was subsequently rolled forward on an annual basis. As of April 2019 the scheme has been commissioned for three years with the option to extend for a further two years.

2.      Days / Hours of operation:

The ECP / SP Care Home scheme operates from 06:00 – 00:00, 7 days a week over two vehicles covering the footprint.

  • Car One: 06:00 – 18:00
  • Car Two: 12:00 – 00:00

3.      Which clinicians are involved in the response and how many WTEs (if a specific cohort)?

To fully staff both vehicles operating 2 x 12 hours shifts, 7 days a week, the scheme requires 6 WTE ECPs / SPs.

4.      Which other partners are involved in providing the response?

None, although the CCG Care Home Intervention Team (CHIT) are heavily involved to help educate Care Homes use the service instead of simply calling 999 inappropriately.

5.      What other key resources are needed for this response to work? (vehicles, specific equipment etc)

The key resources are the Emergency Care Practitioners / Specialist Paramedics (Urgent Care) themselves. There is no specific equipment or vehicles required for the response to work.

6.      How is the initiative funded? (level of engagement/support from CCGs etc)

This service is a separately commissioned service from the local CCG. These commissioning arrangements are now moving towards STP / ICS commissioning arrangements and will potentially be delivered on a wider footprint with the development of EEAST’s Specialist Paramedic development programme.

7.      What were the main facilitators / blockers / interdependencies when introducing this response?

Availability of appropriately trained staff. Primary Care Networks in particular are targeting ECPs / SPs with attractive salaries that EEAST cannot compete with, leaving a staffing gap that impacts delivery of this scheme at times.

Evaluation & Monitoring

1.      What are the key success measures?

  • Number of Care Home patients seen
  • Reduced number of conveyances from Care Homes in comparison to ‘traditional’ 999 response
  • Improved patient outcomes and experience (reduced re-contact rates, etc)
  • Reduced inappropriate use of urgent and emergency services from frequently calling Care Homes

2.      How are these being measured / collated / monitored?  (frequency / who reported to etc)

Deep dives and time and motion studies have been completed by system partners and the Commissioning CCGs.

3.      Has a formal evaluation process been undertaken (independent / inhouse)?

Yes, supplied separately. This has underpinned the trial scheme being commissioned long-term with a 3 + 2 contract.

4.      What are the current findings in terms of the success measures?

  • Contributes to a significant reduction in attendance / admission to acute hospitals
  • Represents value for money when benchmarked against the cost of an acute admission
  • Released capacity within EEAST’s frontline operational resources to attend higher acuity patients
  • Reduced re-contact rates to 999 and / or other unplanned presentations to healthcare services
Sustainability

1.      Does the Trust intend to continue with this response for the foreseeable future?

Yes, as long as the service is commissioned EEAST will continue to deliver the scheme. This is our key response to the aspirations of the Long Term Plan.

2.      What long-term resourcing requirements are there?

Staff with specialist skills that are being targeted by other system providers. A collaborative / rotational approach to staffing should ensure sustainability moving forward.

3.      What risks have been identified (for patients / Trust / system) in providing this service and how have these been mitigated?

The biggest risk is the employment opportunities Primary Care Networks (PCNs) are offering, with salaries and terms and conditions the emergency ambulance services cannot compete with.

We are currently exploring Paramedic / Specialist Paramedic rotational offers with bot the PCNs and other system partners to retain our staff, whilst providing opportunity to work across different sectors to improve skills, knowledge and experience.

4.      Is there potential to expand this response model?

Yes, although the staffing model needs to be clearly protected to ensure delivery of the scheme.

Sharing & Learning

1.      What has the Trust learnt most from introducing this process?

Care Home staff are generally under-trained and under-invested in. With support from specialist staff they can be considerably upskilled, feel more confident and make a significant difference in patient care, outcomes and experience, whilst reducing the burden on an overstretched urgent and emergency care sector.

The ECPs / SPs also complement services provided by Primary Care and with a coordinated approach, these patients can be kept out of hospital in most instances where appropriately identified for this scheme.

2.      What might be done differently with the benefit of hindsight if implementing again? (in another part of the trust for example)

Only committed to a second vehicle once the first vehicle was robustly staffed, adding a second vehicle too early spread the team of ECPs / SPs too thin and service delivery suffered.

We have now recruited to establishment and these issues have been resolved, however, availability of specialist staff is not always where and when they are needed.

Additional Information

Read the EIV Evaluation Report here.

ScHARR Evaluation

This Initiative has been the subject of an evaluation review by ScHarr – read the report here.

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