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Providing enhanced patient care at home

The nurse-led Trafford Community Enhanced Care Service in Greater Manchester is supporting 1,000 patients to stay at home, reducing avoidable hospital admissions and GP call outs. 

The nurse-led Trafford Community Enhanced Care Service in Greater Manchester is supporting 1,000 patients to stay at home, reducing avoidable hospital admissions and GP call outs.

In 2011, Lesley Lyons was one of five community matrons in Trafford working to reduce avoidable hospital admissions.

The team of advanced nurse practitioners has helped to reduce hospital admissions. Picture iStock

As advanced nurse practitioners, they worked with nine GP practices to provide support and monitoring for patients with frequent unplanned hospital admissions, helping them to stay at home and reducing GP call outs.

In 2012, the team won approval for a business case to expand the service, which included supporting emergency patients outside hospital. This was in response to plans to downgrade Trafford General Hospitals emergency department service to an urgent care centre, which would put pressure on neighbouring acute hospitals.

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The nurse-led Trafford Community Enhanced Care Service in Greater Manchester is supporting 1,000 patients to stay at home, reducing avoidable hospital admissions and GP call outs.

In 2011, Lesley Lyons was one of five community matrons in Trafford working to reduce avoidable hospital admissions.

Enhanced patient care at home
The team of advanced nurse practitioners has helped to reduce hospital admissions. Picture iStock

As advanced nurse practitioners, they worked with nine GP practices to provide support and monitoring for patients with frequent unplanned hospital admissions, helping them to stay at home and reducing GP call outs.

In 2012, the team won approval for a business case to expand the service, which included supporting emergency patients outside hospital. This was in response to plans to downgrade Trafford General Hospital’s emergency department service to an urgent care centre, which would put pressure on neighbouring acute hospitals.

A service is born

It was from these humble beginnings that the Trafford Community Enhanced Care Service was born. Today, Ms Lyons is clinical lead for a community service that supports 1,000 patients across the borough, in partnership with 36 GP practices and five acute hospital trusts.

Launched in November 2013, the nurse-led service is run by the Pennine Care NHS Foundation Trust. It provides multidisciplinary care at home for patients at risk of avoidable hospital admission, including 24/7 access to urgent care, intensive support and enhanced care packages for medically stable patients.

Ms Lyons says one of the biggest challenges in setting up the service was recruiting enough nurses with advanced or specialist skills. ‘There weren’t that many people out there, so we had to train people along the way,’ she says.

Thinking differently

‘We needed people who were flexible and willing to think differently. We were lucky in that we managed to recruit good, dynamic staff.’

The team is made up of nurse practitioners in advanced and specialist roles, including in heart failure, dementia and intravenous therapy. There are also eight therapists, two pharmacy technicians and one social care assessor. Two geriatrician consultants from Wythenshawe Hospital provide home visits.

In the 9-month period, from April-December 2014, the service supported 2,996 referrals. This prevented 760 hospital admissions and 1,543 emergency department attendances, saving £1.3 million and reducing pressure on acute services.

High satisfaction

A survey showed high patient satisfaction, with 88% of service users saying they were treated with dignity and respect and 76% responding that they were satisfied with their care.

Most patients are referred by GPs, paramedics, community matrons and hospital consultants (see table below). There is a single point of access: all calls go through a triage nurse who decides if the case is urgent or routine before referring it on to one of four neighbourhood teams.


Referrals in the period March-July 2016

Referral source

Total

%

Ambulance service 56 4.6%
Care home/hospice 16 1.3%
Community services 309 25.4%
General medical practitioner 304 25.0%
Hospital 324 26.6%
Internal 140 11.5%
Not recorded 15 1.2%
Other source of referral 4 0.3%
Self-referral 1 0.1%
Social services 48 3.9%
Total 1217 100%

Source: Trafford Community Enhanced Care Service


Patients immediately at risk of hospital admission are classed as urgent and seen within 6 hours. They are given rapid access to an enhanced health and social care package at home, usually for up to 72 hours, followed by a seamless pathway to ongoing care.

Self-managing

Those who are medically stable are classed as routine and are seen within 8 days, when the team agrees a management plan with the patient and their family.

These are often patients with long-term conditions or ageing-related problems, but the team also covers unusual or complex needs. Patients are empowered to self-manage their condition at home, supported by specialist care if required which can be stepped up or stepped down as necessary.

The rapid and specialist response means GPs and paramedics can refer urgent patients as an alternative to the emergency department. The service also works with hospitals to take patients within 24 hours after presenting to the emergency department, and 72 hours for people in the older people’s assessment and liaison service.

No criteria gap

‘People over 75 years of age tend to need a bit longer to be assessed and stabilised in hospital,’ says Ms Lyons. ‘But if they are kept longer, they can deteriorate very quickly and have a long length of stay. We can prevent this by caring for them at home.’

What makes the service different, she says, is that it avoids restrictions that can cause patients to fall through the referral ‘criteria gap’.

‘Patients have to be at risk of hospital admission and they have to be over 18 – and that’s it. We don’t restrict ourselves to any kind of medical conditions.’

Flexible approach

Also important is the team’s multidisciplinary and flexible approach, which leads to a seamless service. ‘I have worked with services where they say “this is not our problem”. They refer out and it all gets disjointed,’ says Ms Lyons.

‘But we sit down together as a team, do joint visiting and get to grips with the problem. We do whatever we can to prevent people ending up in hospital.’

This ranges from giving injections to prevent severe cyclical vomiting in a woman with a hormonal condition – and offering her family a typewritten script they can deliver over the phone should it fail – to helping a man with mental health problems buy carpets and clothes, or doing call out visits in agreement with his mental health worker.

Home assessment

The key is assessing patients in their own environment. ‘When you see patients over a period of time in their own home, you get a totally different picture than in that one visit to the hospital,’ Ms Lyons says.

‘As you build that relationship up, you find out what’s happening in their lives and what their needs are, so the patient gets better care.’

She says the team works continuously to engage its service partners. There is a link nurse in every GP practice, and staff make regular visits to local acute hospitals, especially the emergency department and admissions units.

Making it easy

‘It’s about the constant advertising of your service. You’ve got to make it easy for referrals and to refer in,’ says Ms Lyons.

Gill Eccles is one of the original community matrons. She now manages a neighbourhood team with a caseload of around 225 patients.

‘We are constantly reviewing the caseload, moving people up and down, and increasing or decreasing the frequency of visits,’ she says. ‘Every time we discharge a patient, it’s on the proviso that they can always ring and refer themselves back in, so they don’t feel cast adrift.

Empowering nurses

‘I try to empower nurses at all grades to think – every time they go and see someone – what is it we’re not meeting? And if they’ve had an admission, what happened in that admission, and what could we do next time to prevent that?

‘There is nothing we don’t do. You do what you need to do to keep that person at home,’ she adds.

New developments for the service include training more nurses in heart failure and dementia care and increasing hospital in reach work, including a proposal to extend criteria for urgent referrals so all patients are accepted within 72 hours of presenting to the emergency department, instead of the current 24.

Implementing change

‘The biggest challenge is being able to change and implement change,’ says Ms Lyons. ‘We’ve only been running this new service for 3 years and the amount of change we’ve made – and the things we’ve done to get the service where it is – has been massive.

‘Although staff can find this challenging, as a team it’s been fantastic. I don’t think I’ve ever worked in a team like this. I’m proud to say we’ve done it.’

Top tips for setting up a community enhanced service

  • Avoid restrictive referral criteria
  • Be flexible and willing to change
  • Develop your staff to meet local needs
  • Work continuously to engage GPs and other partners
  • Ensure consultant involvement


Ann Dix is a freelance writer

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