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Preventing hospital admissions and improving end of life care: a team approach

How the RCNi Nurse Awards Team of the Year integrates physical and mental health services

How the RCNi Nurse Awards Team of the Year integrates physical and mental health services for care home residents

  • Multidisciplinary team covers 52 care homes and 1,750 beds in north London
  • Service is responsible for 35% reduction in emergency department attendances and non-elective admissions
  • Teams work has continued throughout the COVID-19 pandemic to support vulnerable residents
Clinical lead Melanie Pettitt (top left) with fellow members of the award-winning Care Home Assessment Team in North London

A nurse-led multidisciplinary team that helps prevent hospital admissions and improves end of life care for residents in care homes has been named Team of the Year in the RCNi Nurse Awards 2020.

The Care Home Assessment Team (CHAT) at Barnet, Enfield

How the RCNi Nurse Awards Team of the Year integrates physical and mental health services for care home residents

  • Multidisciplinary team covers 52 care homes and 1,750 beds in north London
  • Service is responsible for 35% reduction in emergency department attendances and non-elective admissions
  • Team’s work has continued throughout the COVID-19 pandemic to support vulnerable residents
Clinical lead Melanie Pettitt with 12 fellow members of the award-winning Care Home Assessment Team in North London, four holding a CHAT sign
Clinical lead Melanie Pettitt (top left) with fellow members of the award-winning
Care Home Assessment Team in North London
RCNi Nurse Awards logo

A nurse-led multidisciplinary team that helps prevent hospital admissions and improves end of life care for residents in care homes has been named Team of the Year in the RCNi Nurse Awards 2020.

The Care Home Assessment Team (CHAT) at Barnet, Enfield and Haringey Mental Health Trust covers 52 care homes and 1,750 beds in north London.

Around 80% of residents have dementia, 60% have poor mental health and many have multiple chronic health conditions.

CHAT was established in 2012 when it became apparent that people with dementia were experiencing inappropriate hospital admissions and poor end of life care, and care homes were struggling to manage mental health and long-term conditions.

Team’s service ‘puts people at the centre of their care’

CHAT clinical lead Melanie Pettitt

‘We found that some care home staff lacked confidence,’ says community matron and CHAT operational and clinical lead Melanie Pettitt. ‘And we sometimes lacked responsiveness from primary care.

‘Our community service colleagues were struggling with the care homes’ needs and the homes were highly varied in size and capability.’

The CHAT service was designed to put people at the centre of their care, enabling residents and their loved ones to be involved with treatment decisions and care planning.

The CHAT community matrons – Jane Jones, Jane Castle, Joyce Khelawon, Vinny Carpenen, Julia Foot, Nneka Agbasi, Natasha Sheppard and Ratna Chureetur – along with care home nurse specialist Lynda Jeganathan, offer a wide range of proactive support to the care homes.

This includes new resident reviews including comprehensive care planning and risk assessments, post-discharge reviews, family meetings and discussions about future wishes. There are also clinics that review medications and do not attempt resuscitation (DNAR) notices, a geriatrician-led falls clinic, and dementia assessments in the care homes.

‘Residents can access consultant geriatrician and psychiatry support via CHAT, which ensures that even the most complex needs can be reviewed and plans made without escalation to hospital,’ says Ms Pettitt.

If an admission is required, CHAT acts as the Trusted Assessor to aid communication between care home and hospital to facilitate safe discharges.

‘During our busiest week of the COVID-19 pandemic, we saw requests for palliative support increase by 200%’

CHAT clinical lead Melanie Pettitt

The CHAT team includes Kamla Bhoyraz, the trust’s nursing lead for mental health, who has made sure physical and mental health are fully integrated.

The team also includes a mental health occupational therapist who delivers training and support in care homes.

‘This focuses on the environmental management of behaviour and has reduced the need for medication, improving outcomes for residents and reducing risk factors from falls and medication,’ says Ms Pettitt.

Find out about the rest of our RCNi Nurse Awards 2020 winners

A resident at Autumn Gardens Care Home in Enfield
A resident at Autumn Gardens Care Home in Enfield

Integration with social and care services has also been a key aim from the start.

‘CHAT works in partnership with care homes, GPs, community health and therapy professionals, acute trusts, voluntary organisations and social services to enable a coordinated approach to meet a person’s needs,’ says Ms Pettitt.

If a resident experiences a physical or mental health crisis, there are rapid response visits and an urgent same-day phlebotomy service, and CHAT is the first-line response for palliative care in the care homes it covers.

Significant reductions in hospital admissions

A strong focus on audit has ensured the service can show impressive results, including:

  • A 35% reduction in the number of emergency department attendances and non-elective admissions in all CHAT-managed care homes, from 6,059 in 2013-14 to 3,941 in 2017-18.
  • This compares with a 23% increase in admissions of people aged 65 years and above in Enfield’s non-care home population over the same time period.
  • The team also achieved its aim to improve end of life care, with 99% of deaths occurring in the residents’ preferred place over the same time period.

CHAT’s service has continued throughout the pandemic, including allowing residents to die in their preferred place, and teaching the safe use of personal protective equipment to care home staff.

‘The COVID-19 pandemic affected care homes particularly, and having an integrated service working in partnership with others was paramount to support vulnerable residents,’ says Ms Pettitt.

‘Despite the increased workload and staff shortages, our passionate and committed team never stopped visiting throughout the pandemic. During our busiest week we saw requests for palliative support increase by 200%.’

‘This team has walked with us, improved care, and we are now seeing that our residents are getting the best’

Daniel Ejelonu, manager of Fouracres Care Services

Care home managers are grateful for their support. Mariana Yaneva, manager of Maison Moti Care Home in Enfield, says CHAT ‘provides incredible knowledge and expertise in an area where we sometimes feel like lone warriors’.

‘Physical health is so important and is always related to mental health, so we can’t support someone’s needs holistically if we don’t look from every angle,’ she adds.

‘That’s what I have found the CHAT team to be about – they are extremely open-minded and supportive. Working with them has helped ensure we did not have any COVID-19 cases.’

A ‘one-stop shop’ service to care home residents

Daniel Ejelonu, manager of Fouracres Care Services in Enfield, agrees the team is invaluable. ‘Before now it has always been a struggle getting healthcare professionals to attend to our residents.

Daniel Ejelonu, manager of Fouracres Care Services
Daniel Ejelonu, manager of Fouracres
Care Services

‘With CHAT there has been a big leap in the way we meet our residents’ health and care needs. It is a one-stop shop. When the matron comes in, she looks at everyone’s documents and receives updates on their health. She will not hesitate to act on the spot. This team has walked with us, improved care, and we are now seeing that our residents are getting the best.’

The RCNi Nurse Awards Team of the Year category is sponsored by LV.

LV’s Gavin Stroud says the CHAT team was a worthy winner in an exceptional group of finalists.

‘This team’s passion and commitment to improve the care of patients in care homes since 2012 is fantastic, and, coupled with the significant reduction in both costs and time for the NHS, this initiative is truly amazing.’

Ms Pettitt says winning the Team of the Year award will be a ‘fantastic springboard to share CHAT’s learning’.

‘This is an easily replicable model,’ she says. ‘CHAT is a team effort and to be recognised for the work it does with a very complex population, and the impact the service has had for care homes, the residents, their families and the care home staff, is truly humbling.

‘This is not only recognition for CHAT but also for every care home we work with and the amazing work we do together.’

How to integrate physical and mental health services

Melanie Pettitt, clinical lead of the RCNi Nurse Awards Team of the Year 2020, gives her top tips on developing and managing a multidisciplinary service integrating physical and mental health care for older people.

1. Know your demographic – In Enfield we have a large number of care home beds compared with many neighbouring London boroughs, so there was a clear need to join up how we support this large vulnerable population. We also reviewed admission data to our local acute trusts and found that a significant proportion were from residents from care homes, which again identified the need.

2. Understand your existing services – It often isn’t cost effective to have every discipline in every service. In CHAT we have mental and physical health nursing and therapy staff, with support from consultant geriatricians and psychiatrists, as our core offer. Just as important are our close links with primary care, community therapy and specialist nursing services, which are not part of our core staffing. By having direct referrals and clear pathways for access, we can utilise existing, well-established and respected services rather then re-inventing the wheel and having all disciplines within our care homes service.

3. Partnership working reduces duplication – Spending time getting to know what the local authority, clinical commissioning group, continuing health care team, voluntary sector, private sector, primary care providers and acute trust already provide can help map out gaps and reduce risk of duplication. Where there is crossover and similarities, partnership working can be agreed for better use of resources and improved outcomes for service users.

4. Listen to the voices of service users and carers – They are essential to ensure multidisciplinary and integrated services truly meet their needs. We held engagement events with care home staff, managers and owners, and sought feedback from carers’ forums and groups. We continue to hold yearly events to gather quantitative and qualitative feedback to shape the service we provide.

5. Working in a multidisciplinary team in an integrated way up-skills all staff involved – Within our care homes service, our occupational therapist can manage low-level medication enquiries, our physical health nurses can manage low-level mental health needs, and our mental health nurses can manage low-level physical health needs. This aids learning and development of staff, which helps staff retention and satisfaction.

6. Meaningful data collection is key – Nurses and therapists work incredibly hard to improve the health and well-being of care home residents, but the data we can provide to evidence this is what grew CHAT from a pilot with four care homes to a substantive service of more than 50 care homes across two London boroughs. It also enabled us to be recognised by NHS England as an example of best practice for care of older people and dementia care, and provided our evidence to the RCNi Nurse Awards judges, leading us to winning Team of the Year.



The RCNi Team of the Year Award is sponsored by LV

LV, Liverpool Victoria logo

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