1 October 2018

Project story: Enhanced Care to Nursing Homes

This is a story capturing the impact, and unexpected outcomes by breaking down the silo at work as a result of their quality improvement (QI) project. Hear it from the Rapid Response team in Community Health Newham on how they engaged and collaborated with external partners to provide enhanced care service to residents and staff at six care homes in Newham to reduce unplanned (emergency) hospital admission.

We interviewed the project team Daniel Franey, Operational Manager; Jean Reilly, Clinical Lead; and Tracey Campbell, Specialist Care of the Elderly Nurse for the Rapid Response team in Community Health Newham.

Why is providing an enhanced support service to care homes important?

There is much written about ways in which people can be supported at home to avoid the disruption and stress of a hospital admission. We know that elderly care home resident are at increased risk of requiring emergency hospital admissions compared to the general population, due to the higher prevalence of chronic disease. The Rapid Response team therefore provides an enhance support service to nursing homes, supporting their staff in managing complex needs, and those who are most likely at risk of an emergency non-elective admission into hospital. We hope by doing so, we are able to keep and treat more residents at home, with the staff they know. This also helps to minimise unnecessary cause of distressed to the elderly patients.

Before starting the QI project, on average, the Rapid Response team received 11 referrals a month from nursing homes in Newham requesting for our service. We know we needed to change the way we work, be proactive rather than reactive in delivering our service to more nursing homes. As Daniel Franey, Operational Manager of the Rapid Response team highlighted: “When you are there [care home], they [care home staff] ask you questions but when you are not there, they only ring when they are worried. We want to change this.”

What was the aim of your QI project?

By July 2018, we wanted to:

  • Increase referrals to the Rapid Response team from six nursing homes by 20%.
  • Reduce unplanned hospital admissions from six nursing Homes by a minimum of 10%.
  • Reduce the average length of stay in hospital for Nursing Home residents by 30% (from 14 days per admission to 10 days)

Did you achieve your aim?

Around 12 months after we began testing change ideas, we have seen a 255% increase of referrals to the Rapid Response team. This is an increase from the monthly average of 11 to 39 referrals. We have also been able to sustain this improvement.

 

Our second aim of this project was to reduce admission to Newham University Hospital Trust (NUHT) by a minimum of 10%. This was an ambitious objective, and it was challenging to obtain the admission data. However, we were able to get data from the London Ambulance Service (LAS) on the number of calls made from the six of nursing homes each month. The data on the I chart below demonstrated common cause variation in the number of calls to LAS since the project started in July 2017. May, June and July 2018 saw fewer calls than the average of 39.45 calls to LAS each month. However, we will need to continue to monitor the data to ascertain whether this early sign of reduction is a true signal for special cause variation and we can be confident to conclude there has been a statistically significant reduction.

 

Although the numbers of patients taken to NUHT did not reduced as we hoped, by analysing the calls, we were able to identify a number of themes and trends from data for a cohort of patients who were admitted to hospital. These are useful insights that will be used to inform our service planning, especially during the next winter period.  Learnings are summarised below:

  1. Of the patients conveyed to hospital 87.5% were subsequently admitted for at least two days and an average of six, this would suggest that the calls to LAS were appropriate and in the best interests of the patient.
  2. 75% of the calls to LAS and subsequent conveyance to hospital occurred out of normal operating hours, and occurred between 20:00 and 08:00 outside of the normal operating hours of the Rapid Response Team and wider EPCT services.
  3. 62.5% of the patients for whom an ambulance was called were on the advice of the assessment of the Out Of Hours GP.

Our third aim was to reduce the average length of stay from 14 days to 9 or 10 days, therefore achieving a reduction of 30%. As getting the admission data was a challenge, we were only able to sample the length of stay from a small cohort of patients. After reviewing data from seven individual patient episodes, we saw a 57% reduction in average length of stay, with the average length of stay totalling six nights. It is a positive signal but we recognised the limitation with a small sample size. We would like to have more data over time to be certain that the improvement seen is not due to common cause variation.

What were the key change ideas tested that has led to the improvement seen?

Collaborating with Newham Clinical Commission Group and Newham Social Care to send out a joint communication promoting our enhanced support service. This was felt to be a positive change as previous communications sent in isolation by ELFT had not received a satisfactory response. The combined communication demonstrated a commitment of the part of the three organisations to support each home with desired subsequent buy-in to the project from each home. The communication was followed by visits to each home.

The project was also advertised and promoted on the Trust intranet and internet, garnering additional publicity for the project. The project introduced joint contract and monitoring visits between the nurses in the Rapid Response Team and colleagues in the Contracts & Compliance Team in the London Borough of Newham. The local authority has a statutory duty to review each Nursing Home.  They had previously done this in isolation, without the support of a health professional. The joint reviews enhanced and improved this process.

To ensure proactive and targeted interventions, the project utilised the comprehensive data provided by the London Ambulance Service (LAS) via the Collaboration of Clinical Commissioning Groups. This data provides information on type of illness, reason for call to LAS, frequency in terms of day and time and conveyance to hospital rates. This data enabled the project to map need and identify health conditions that required a particular focus. The data is also discussed quarterly at a dedicated meeting between all the partner agencies, enabling an ongoing process of review and development.

What were the main challenges faced by the team in doing this work and what have you learned from those difficulties?

There were some initial challenges in getting some of the Nursing Homes to engage. Whilst a number of the homes immediately bought into the project and levels of engagement were excellent, some other homes required a little more encouragement. Many of the homes also have a high turnover of staff and at times engagement would drop off because new staff were not familiar with the project. However, the provision of an allocated named nurse enabled these minor challenges to be overcome as regular attendance by a named professional provided continuity and enabled relationships to be developed and maintained.

Another challenge was convincing the Nursing Homes that the project was something that wasn’t being done to them, but rather being done with them. It was explained and clarified that the project wasn’t about monitoring the home, or undermining the care provided, but that it was to support and enhance the good work that the individual homes already undertook. Again a consistent approach and partnership model of working with Nursing Home staff ensured this challenge was quickly overcome.

What is next for the Enhanced Care to Nursing Homes QI Project?

“There has been unexpected outcomes as a result of this QI project,” said Jean Reilly, who is the Clinical Lead for the Rapid Response team. “Our nurses are more confident and building trusting relationships with the GP practices in Newham. This is also reflected where GP prescribers have agreed to mentor our nurses who are undergoing their nursing prescribing course.”

Jean Reilly & Daniel Franey

We are very pleased with what we achieved so far, and as Daniel Franey, Operational Manager for the Rapid Response team sums it up nicely, “little changes can do a lot”. The team recognised that all aspects of the project will continue to run as business as usual, and it will be subjected to ongoing assessment and review. The three organisations will continue to work together to provide a systemic package of care to nursing home residents. Ongoing data collection and liaison will ensure any changes in need can be met in a proactive and timely manner. For example, the Clinical Commissioning Group is currently reviewing GP input the Nursing Homes and exploring new models of working. They have also requested that the Rapid Response Team be a part of this work. The team also hopes to link in to London and nationwide networks who undertake similar types of work. It is very much hoped that this good work will continue and be scaled up and spread.

The initiative was jointly set up and overseen by The Newham Clinical Commissioning Group (CCG), represented by Coral Alexander; London Borough of Newham, Adult Social Care Contracting Team, represented by Sarbjit Rai; and East London Foundation Trust.


If you are part of ELFT you can learn more about this project on Life QI here – Project code 104345

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