Safely Reducing Avoidable Conveyance Programme

Falls – Early Intervention Vehicle (EIV)

Brief Description of Initiative

The Early Intervention Vehicle (EIV) provides an immediate response, via carefully triaged 999 calls or via inter-crew referrals, primarily to patients aged over 65, operating twelve hours a day, seven days a week. The EIV will typically respond to patients who have fallen, or those otherwise deemed appropriate for intervention with a view to treat and discharge their care within the community.

The service is offered as a partnership between EEAST and local Community, Acute and Social Care providers.

The EIV generally incorporates a (Occupational or Physio) therapist from the local Community, Acute or Social Care provider, working alongside EEAST. The objective is a joint assessment at the initial point of contact to provide safe admission avoidance solutions, and / or referral to appropriate care pathways. A typical assessment process would be holistic and include medical, functional, environmental and personal care assessments with recommendations for current or future requirements. The patient’s own GP would also be involved in any treatment decisions where the patient is expected to be managed in the community.

Services provided include (but not limited to):

  • Community based activities of daily living assessments including medical, social and functional needs
  • Supply and provision of mobility equipment and minor aids, with direct referral for major home adaptations, i.e. wet rooms, stair lifts, etc
  • Implementation of new or increased social care provision
  • Sign-posting to statutory and voluntary organisations
  • Support and advice to service users, and their carers, to prevent or minimise the risk of an avoidable future crisis

Date Initiative was introduced in Trust

The schemes initially started as a pilot from NHS England Vanguard funding in early 2016.

Date of upload or review

Uploaded to Repository 1st January 2020.

Background Context

One in three people aged over 65, and half of those aged over 80, fall at least once a year (Todd and Skelton 2004), accounting for more than 4 million bed days (Royal College of Physicians 2011). Falls are the commonest cause of death from injury in the over 65s, and many falls result in fractures and / or head injuries. Falls cost the NHS more than £2 billion per year and also have a knock-on effect on productivity costs in terms of carer time and absence from work (Snooks et al 2011). With the number of people aged 65 and over predicted to increase by 2 million by 2021, costs are set to rise further.

Deconditioning in older hospitalised patients is consistently reported, more often due to hospitalisation rather than presenting medical illness. 10 days in hospital, acute or community, leads to the equivalent of 10 years ageing in the muscles of people aged over 80. 48% of people over 85 die within one year of hospital admission.

The potential consequences of falls are wide ranging:

  • Physical Consequences: Injury, pain long term disability, decreased ability to care for oneself
  • Social Consequences: Loss of independence, social contacts, home, potential move to residential care, financial costs of care, decreased quality of life, changes to daily routine
  • Psychological Consequences: Loss of confidence, fear, distress, guilt, blame, anxiety, embarrassment

Early intervention schemes aimed at targeting, high-risk vulnerable patients can deliver improved, sustained performance and significant savings across the Health and Social care systems. These early intervention schemes create cost savings through direct care and treatment in the community, and / or signposting patients to alternative care pathways appropriate for the patients need, rather than conveyance to the Emergency Department (ED).

Which specific patient group or presenting need is this response targeted at?

The frail elderly – over 65s that have fallen within their own home (incl. Residential and Nursing Homes).

The EIVs will be deployed according to defined parameters, predominantly calls prioritised as Category 3 / 4 meeting the following criteria:

  • Patients who do not have any red flag conditions and are triaged through MPDS Protocol 17 – ‘Falls’
  • Patients who have fallen with associated co-morbidities
  • Patients who are identified as appropriate for the scheme following clinical triage will also be considered for dispatch. These patients will primarily be triaged within the MPDS Protocol 26 – ‘Sick Person’
Geographical area or location covered by this response model

Covers various geographical areas across Bedfordshire, Hertfordshire, Norfolk, Suffolk and North Essex, both urban and rural. We have schemes operating in 4 of our 6 STP footprints. The East of England has a higher than national average elderly population, particularly across Norfolk and Suffolk.

Key Aims

The primary role of the scheme is to provide holistic assessments to safely care for people within their own home, including both Nursing and Residential Homes, to reduce hospital admissions, helping older people to live independently.

Aims Outcome Criteria
Maintaining independence and functional improvement through provision of a more timely and appropriate response to falls •    reduction in 999 calls to fallers
•    reduction in admissions to A&E for a fall
•    reduction in number of neck of femur fractures
•    increase in the number of people receiving an initial falls assessment
•    increase in number of referrals to falls clinics
•    increase in referrals to tele-care for falls
Improvement in follow-up care and education for falls •    service response more commensurate to patient need.
•    more timely initial assessment for a fall
•    more timely access to specialist / geriatric assessment and care
•    more people receive information and education about falls management
Improved clarity for staff involved in individual patient’s care; the best way to manage the causes of the falls and the most appropriate way to manage a fall where it occurs •    improved information sharing across services and agencies
•    clear clinical guidance on the management of the individual
•    reviews of the patient’s physical health, functional ability, cognitive function, nutritional status, mobility, risk of further falls and an environmental assessment
Improvement in the patient experience of services •    increase in privacy and dignity for patient
•    patient feels helped to remain independent
•    reduced level and duration of stress
More effective use of skills and resources within the Ambulance Service •    better response time to life threatening calls
•    more cost effective service

 

Benefits for Patients
  • Patients benefit from staying at home, improved patient outcomes and experience
  • Care within their own home or community, increasing independence
  • Minor home adaptions can be made immediately

The main benefit to patients is care closer to home. Across many sections of society, being conveyed to ED to receive care can solve immediate health care needs, but will often be detrimental to patients longer term wellbeing. For many older people, their ability to care for themselves is within a local infrastructure of family, neighbours and local support mechanisms.

Taking a patient miles to the local secondary care provider often reduces the patent’s confidence to cope alone at home. Once this confidence is broken, their chance of being able to cope alone again in their community is reduced, even though the local support is still in place. With limited social care options, or time required to put packages of care in place, this disadvantages the likelihood of restoring independence.

It is therefore imperative that wherever possible, patients are treated closer to their own community and Early Intervention Schemes have been developed around this very model of care specifically to do this.

Benefits for Trust or System
  • Collaboration – brings system working together
  • Less complex older patients conveyed / admitted to hospital
  • Opens up more referral pathways to the patient

This patient group tend to have higher rates of comorbidities, and the reduction in self-confidence can exacerbate difficulty with coping mechanisms alongside long-term illnesses. In turn, this is likely to lead to increased reliance on the health system across Primary, Community and Secondary care providers. Many patients will also use ambulance and ED services as emergency solutions to cope with their on-going healthcare, especially when conditions are left unmanaged and result in crisis.

Whilst at the outset this is primarily an admission avoidance initiative, the patient interaction soon creates an appropriate (frequent) call avoidance scheme and reduces the longer-term impact on health systems overall. The benefits include a potential reduction in demand on ED attendance and associated admissions that often have excessive Lengths of Stay (LoS), increasing patient flow through the hospital, improving the nationally reported ‘bed blocker’ scenarios.

Consequently, the EIV schemes are likely to have a positive impact on hospital handover delays if fewer patients are being conveyed. A greater number of emergency ambulances will be freed up to respond to calls in the community, promoting patient safety to our sickest patients.

This directly reduces avoidable burden on the expensive urgent and emergency care sector. Fewer emergency admissions to inpatient wards contribute to an improvement in patient flow through overstretched acute hospitals; fewer conveyances to hospital mean less ambulances queuing at front door, thereby releasing EEAST resource and ability to respond to higher acuity, emergency patients in the community.

The cost benefit to the health system has several aspects to it. Initially, there is the saving of ambulance conveyance and hospital attendance / admission, and then the longer-term cost savings of the post discharge care and treatment required. There are also the cost savings on the impact of the longer-term reduction of demand on the health system overall. Whilst these are often difficult to quantify, even small reductions of activity to each provider results in savings achieved.

Implementation

1.      How long has this initiative been operational?

The schemes initially started as a pilot from NHS England Vanguard funding in early 2016.

Once central funding had ceased, local CCGs decided to commission the EIVs on a long-term basis following successful evaluation.

2.      Days / Hours of operation:

The EIVs typically operate 12 hours per day, 7 days a week (including bank holidays), with varying hours of operation in each area.

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

Both EEAST Paramedics and Emergency Medical Technicians (EMTs) staff the EIVs (dependent on the model commissioned) along with an Occupational Therapist (OT). The number of WTEs vary across the Trust depending on operational hours commissioned, but for one vehicle to operate 12 hours per day, 7 days a week this involves 3 WTEs to include relief.

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

Again, this varies across the Trust but generally it will either be the local Community Services or Acute Provider, and / or the Local Authority / County Council.

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

Specifically adapted Transit style vehicle converted to hold all of the EIV specialist equipment and fitted with blue lights to ensure the team can still respond to C1 calls. Specialist equipment is required to help pick up the patient after a fall, adaptations for the patients home e.g. commode or handrails, etc. This equipment is carried so that it can be prescribed immediately upon initial contact.

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.

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

Availability of appropriately trained staff, including the OTs (who are in short supply across our region).

Also, when introducing this service it was important to have the Emergency Operation Centres (EOC) on board and fully briefed to ensure the vehicle was employed to EIV appropriate calls, and not simply utilised as a Rapid Response Vehicle (RRV) / First Response Vehicle (FRV) to high acuity C1 / C2 calls that are much more likely to require conveyance.

Evaluation & Monitoring

1.      What are the key success measures?

  • Number of EIV appropriate patients seen
  • Reduced number of conveyances in comparison to ‘traditional’ 999 response
  • Improved patient outcomes and experience (reduced re-contact rates, etc)

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 EIVs becoming business as usual and has helped secure funding to expand EIVs across our wider regional footprint.

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?

Requires staff that EEAST can’t always afford to lose from frontline operations, and so long-term planning to incorporate these schemes is vital. They also require a bespoke vehicle to be able to carry bulky equipment and home adaptions.

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

The biggest risk with the EIV is that the vehicle is diverted to C1 calls as the EIV may be the nearest available resource. This often results in the EIV having to wait on scene for lengthy periods waiting for a transportable resource to arrive to convey the patient to hospital. This is inefficient and undermines the commissioned purpose of the EIV.

There is also a risk that we may not be able to staff the vehicles to the commissioned hours, thus losing confidence from system partners in our ability to deliver the schemes sustainably.

4.      Is there potential to expand this response model?

Yes, although there is a point of saturation and EEAST are mindful of the balance required to meet the needs of our population.

Sharing & Learning

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

Collaborative working has been the biggest learning curve and working with the County Council as staff have vastly different employment contracts and scope of practice.

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

The service started without a service specification or contract from the Commissioners; we also had to source vehicles very quickly. In hindsight, thorough system-wide planning around staffing and vehicle specification before the ‘go live’ date would have been helpful. The lead times to secure vehicles with appropriate conversions should not be underestimated.

We are now considering how we further develop these schemes to support our Specialist and Advanced Paramedic pathways.

Additional Information

Read the EIV Evaluation Report here.
Click the following links for more about EEAST’s Early Intervention Vehicle:
https://www.eastamb.nhs.uk/news/success-for-early-intervention-vehicle-pilot-in-norfolk/1725
https://www.eastamb.nhs.uk/news/more-patients-set-to-benefit-as-vital-response-service-expands/2708
https://www.justot.co.uk/occupational-therapy-article-801847925-occupational_therapists_to.html
https://www.gileswatling.co.uk/news/giles-helps-launch-new-local-early-intervention-vehicle
https://www.enhertsvanguard.uk/news/2017/nov/early-intervention-vehicle-helps-keep-frail-elderly-people-out-hospital

ScHARR Evaluation

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

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