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What’s the plan?

24 April 2015

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The Mill Medical Practice in Surrey took on an initiative to ensure patients over 65 were given care plans that would hopefully result in reduced unplanned admissions

It is not often that an initiative is greeted with such enthusiasm and as a positive challenge. However, when the project is made your own and you feel you can make an impact to patient care it is worthy of 100% of your attention.

At the beginning of 2014, Guildford and Waverley Clinical Commissioning Group (CCG) put forth the proposal for GP practices to focus on avoiding preventable admissions and facilitating discharges for all unscheduled admissions, targeting the frail and elderly over the age of 65. This project would be running in parallel with the Direct Enhanced Service (DES) of avoiding unplanned admissions. Although some of the patients overlapped with the DES for this project, we concentrated on our elderly population.

The 21 practices in Guildford and Waverley were challenged with coming up with a suitable, workable business plan to tackle admission avoidance for our frail and elderly population. The business plan would need to incorporate working with a multitude of different agencies with continuous input and liaison. Developing appropriate care plans for patients with chronic disease as well as end of life care. And lastly, reporting and monitoring to ensure the delivery of outcomes for patients.

Business plan
When starting to formulate our business plan, we had to consider that the resources may only be available for one year as the project may not continue. However, our GPs were prepared to take on the challenge, increase partners’ sessions and hire an admissions avoidance liaison coordinator (AALC) on a one-year fixed-term contract with a view to extend. Preparing the care plans and identifying our high-risk patients was the first requirement.

The GPs with the help of the AALC arranged to meet their patients, families and/or carers to discuss and complete care plans. Although this was very time consuming for the individual GPs, it was a very beneficial exercise. Unfortunately though, we have found that well thought through plans don’t always go ahead. In a time of crisis, patients, families and/or carers can and will change their minds about patient care. However, the care plans have proven to benefit the patients, the ambulance service (South East Coast Ambulance Service (SECAMB)), the community matron, district nurses and our care homes.

One crucial aspect of our business plan was the dedication and commitment from our lead GP. You need one leading force to make the plan viable and continuous. Our GP partner leads the virtual ward every week, working closely with our community matron and our AALC. She also runs our review meetings, attends our locality meetings with our other local GP practices, monitors the outcomes and is involved in the reporting function.

One of the most difficult aspects of the business plan was coming up with a job description and role for the AALC. The successful candidate was a current member of the reception team, which helped tremendously. The role required an independent and proactive worker. They need to be confident and I would recommend non-medical. This way they are not contravened, leaving the care to the clinicians. Their role is to liaise with the GPs, hospitals, care homes, community matrons and families. They are there following up on admissions and discharges. Manage and facilitate the discharge summaries, care plans, ensuring care plans are in homes and on SECAMB’s intelligence based information system (IBIS) patient record system. The AALC will attend regular meetings such as the virtual ward and monthly review meetings. They will also be responsible for completing quarterly reports.

Collaborative working
I have found with this project the key to its success is collaborative working. We could not manage this project on our own and it was great to see the involvement with our other NHS agencies. Not only getting the communication right, it is about getting the information and documentation in the right places and in the right hands. I have to say well done to the CCG for making sure the practice was getting what it needed to the clinical lead and collaborate with our local hospital, Virgin Care and SECAMB. We again have been fortunate to have a good working relationship with our community matron and district nurses. We have now developed a good working relationship with our hospital and SECAMB. Sharing information has been the most valuable part of this project, understanding the patients’ wants, needs and the journey through the different systems. At times, this journey was very fragmented and ownership of transition was lost.

Medicine management
Another key area of focus has been on medicine management that we as a practice have embraced. We are part of a pilot scheme by our polypharmacy pharmacists to review medications not only in our care homes but they are also targeting our patients at high risk of admission and our virtual ward patients to help reduce medicine related unplanned admissions. The pharmacists have made great strides in this project with their face-to-face reviews and again collaborative working between the practice, the patient and/or the care home. The medication changes have also been updated on the care plans to benefit the SECAMB and the community matron and district nursing team. This has proven to not only benefit the patient’s health but reduce medication waste and to save thousands of pounds.

The evidence
The project officially started in April 2014 and by the time we got all our care plans in place, our AALC hired and systems in place we were a few months down the line. Nevertheless, progress has been made and can be denoted by the graphs below.

Guildford and Waverley CCG has mapped the progress to show a reduction in excess bed days at our local hospital for patients 65 and older. Under Domain 3 for emergency admissions we are the 18th lowest in the country for avoidable admissions and we have managed with the use of IBIS to reduce our conveyance rates from 80% to 50%. This is still a work in progress but we are heading in the right direction.

Clinical excellence award
It is great to be nominated but it is fantastic to be recognised and of course win. In December of 2014 our CCG nominated and awarded The Mill Medical Practice the Clinical Excellence in Primary Care. The nomination declared that we were: “Truly deserving of the recognition in the area of delivering clinical excellence.” It is not often practices get recognised for their hard work and dedication to virtually what are requirements and good practice. We normally are told what we need to do and get on and do it to the best of our abilities. As a large practice we usually can manage to achieve our targets and still cover the day-to-day responsibilities of keeping a practice running. However, this award made everyone on the team who was either directly or indirectly involved very proud to be part of the practice.  A little recognition goes a long way and motivates you to continue the hard and sometimes thankless work that goes on behind the office doors.
What the future holds
We do not want to lose momentum, we have come this far and need to endeavour to clear the gaps in our road ahead. Our goals are to avoid unnecessary admissions, reduce inappropriate bed days in hospital, keep the patient in the community, and to offer the best care and a safe environment. It is great to shorten the patient’s hospital time and get them out of hospital but what happens next? Do we have enough care in the community? Are there enough nursing or care homes for respite and/or rehabilitation? With the threat of local care homes closing, the government needs to step back and have a look at the impact this will make. As recommended in other areas around the county, we are looking towards volunteer organisations, will this be enough?

Robin Forward is a practice manager in Godalming, Surrey.