Integrated Crisis Response
Through HRG analysis, Leicestershire's BCF plan has identified a proportion of hospital admissions in Leicestershire that can be avoided if we can respond rapidly to crisis situations, such as sudden/temporary changes in the levels of personal care needed at home. The aim of the Integrated Crisis Response Service is therefore to provide effective short-term support at the point of crisis that will help to maintain someone in their own home.
This means that the service will be able to offer short term nursing for those in crisis (up to 72 hours) to avoid admission to hospital or nursing home placement. The service will be available 24/7 and includes taking referrals direct from A&E, with a response within 2-4 hours.
Rapid Assessment for Older People
Usually GPs have to refer older people into hospital in order to evaluate their condition due to the type of diagnostic tests this can involve and/or the need to access a specialist geriatric opinion. This can have unintended consequences such as resulting in an admission, a longer hospital stay than necessary and/or followed by difficulties/delays in discharging them back to their usual place of residence, particularly if their care needs have changed.
To improve this care pathway and avoid admission to hospital, it has agreed to implement a new community based rapid assessment service for older people. This is called the Frail Older Person’s Unit and is accessed at Loughborough community hospital, operating on an outpatient basis. A multidisciplinary team including medical, nursing and social care professionals will see up to 20 patients a day in this service once fully established.
Urgent Response Falls Service
It has been identified that approximately 15,000 people in Leicestershire call East Midlands Ambulance Service (EMAS) as a result of a fall each year. Approximately 7,000 of these calls result in a patient being conveyed to hospital and approximately 2,000 are admitted as result of an injury due to a fall. In other health and care economies it has been demonstrated that community based alternatives to admission can be implemented which prevent a significant proportion of these unnecessary hospital journeys and admissions.
By working with EMAS and Leicestershire Partnership Trust we will change the pathway of care for people who fall in Leicestershire and offer them a rapid response in the community. This will assess the need for hospitalisation, and if this is not required, offer any treatment or follow up support that may be needed in their usual place of residence instead. There are 2 cohorts of patients in the pathway – those that will be treated in the community by the ambulance service, and those who will be routed through the single point of access and receive support from the integrated health and care team in the locality.
The urgent response for falls is only one part of the falls pathways which will be supported by a medium term falls prevention approach.
7 Day Services in Primary Care
We know that our ageing population are susceptible to a number of long term conditions such as Osteoarthritis, cardiac failure, chronic airways disease as well as minor conditions that impact on their health. The King’s Fund report Making Health Care Systems Fit for an Ageing Population (The Kings Fund 2014) highlights the need to transform services for older people and shift towards care co-ordinated around the full range of the individual’s need, rather than based around single diseases.
Both CCGs have developed pilot schemes aiming to test how their localities (healthcare professionals including community nurse teams, pharmachists and the out of hours service) can offer services and support on a 7 day basis to patients with complex needs. Particular emphasis is placed on ensuring the pilots integrate with community based care to avoid unnecessary admissions to hospital.
Source: Leicestershire County Council BCF Submission Annex 1 Integrated Urgent Response
Our Scope
The SIMTEGR8 project will evaluate the four interventions outlined above aimed at reducing emergency hospital admissions.
Interventions