Leading change

The Emergency Nurse Practitioner and Clinical Nurse Lead for Digital Health at Tameside and Glossop Integrated Care NHS Foundation Trust (TGICFT) led the implementation of a digital service that has significantly reduced avoidable admissions to the emergency department (ED), improved experiences for nursing and residential home service users and staff, as well as improved use of resources locally.

Where to look

The ‘Safe, compassionate care for frail older people using an integrated care pathway’ report (NHS England, 2014) provides practical guidance to support safe compassionate care for frail and older people and highlights that these individuals are at greater risk of poorer outcomes and harm if they are delayed in the ED.

The Long Term Plan (2019) highlights that digital technology can support the NHS to deliver high quality specialist care more efficiently, thus reducing pressures on emergency and urgent care services. In relation to the frail and elderly, this can mean assessment and treatment within the safety of their home environment by clinicians with a range of skills not normally seen outside of the hospital environment.

As part of the Trust’s integrated care and transformation project around population health, it was identified that there was a high number of attendances to the ED from nursing and residential home service users which could have been better supported if the homes had wrap-around care services. The Emergency Nurse Practitioner and Clinical Nurse Lead for Digital Health used this evidence of unwarranted variation in practice to lead change.

What to change

The nursing leads identified that General Practitioners (GPs) were unable to meet the increasing needs of care home residents which was impacting on increased referrals to the ED for care. This subsequently placed additional pressures on local EDs, as well as leading to poor resident experience, and possibly poorer outcomes associated with a lack of continuity of care and at times long stays away from their homes. The nurses in collaboration with care sector leads identified that a quality improvement initiative could improve access to healthcare for residents and in turn reduce the number of unnecessary attendances to the ED.

The Emergency Nurse Practitioner and Clinical Nurse Lead for Digital Health visited an NHS Foundation Trust with an established telemedicine service to identify how they were using this to support care homes across the country. This project had demonstrated a 45% reduction in this patient groups’ attendance to the ED. The Emergency Nurse Practitioner shadowed a nurse at Airedale whilst they were supporting care home residents and along with other nursing colleagues, including the Head of Patient Flow, identified this as a possible option for TGICFT.

How to change

Following observations of the digital service, the Head of Patient Flow shared a vision for a new digital service with colleagues, emphasising the need for a model bespoke to TGICFT.

A working group was established to develop the digital application and in March 2017, as part of the Trust’s integrated model of care, the Digital Health Centre (DHC) was launched, initially led by the Emergency Nurse Practitioner as a 6-month pilot with four local care and residential homes.

Residential and care home staff were provided with education, training and support to undertake basic observations such as blood pressure readings and the monitoring of heart rate whilst using video conference software. A pathway of treatment and referral was developed so that when a resident within the home(s) became unwell, staff have an option to speak directly to nurses at the Trust who will be on hand to give advice and guidance through a video conversation as well as use emergency services.

To support the new service, regular meetings between staff from the DHC and care homes took place to discuss what was and was not working, reflect on clinical situations and outcomes, discuss testing or changing processes, and share feedback honestly and openly. In addition, the Emergency Nurse Practitioner and Clinical Nurse Lead for Digital Health met with each home in the area individually to discuss the service and address any worries or concerns. This supported the staff to ensure they fully understood the complexities of the care home providers and their residents and tailor the support to meet these needs.

After just 4 weeks, due to the success of the pilot, the service was rolled out further across Tameside and Glossop, appointing 6 clinicians to support the nursing and residential homes. The DHC has also expanded to include a range of services so that now patients living in the Tameside and Glossop area with long-term conditions are supported with telehealth solutions. GP attendance or hospital admissions are retained for emergency situations by offering these patients advice and guidance, commencing patients on rescue medication and having robust care plans in place.

GP referrals for care home residents and the wider local population into the Trust’s medical teams are now managed via the DHC. This supports effective responses by teams who can assess the individuals as well as supporting care to continue to be delivered in the right place.

The DHC works closely with local Ambulance Services. Staff in the DHC have access to the 111 and 999 call-stack for Tameside, where the lower acuity patients are reviewed, triaged, GP appointments or alternative transport to hospital is arranged as required.

All care homes across Tameside and Glossop are now using the digital service and there is now a team of 9 digital assessors in place who are senior nurses with experience in A&E, community, diabetes and long-term health conditions. There is now a nonmedical prescriber within the service so the benefits of this are expected to increase.

Adding value

Better outcomes – Calls are continuing to increase to the DHC and by January 2019 there had been in excess of 8500 Skype consultations for care home residents with an associated 2500 ED attendances avoided. There has also been a 30% reduction in care home residents having to attend the ED due to services being available within the homes. The benefits to local GPs are that a triage service is provided so there are reduced calls and, although some patients require visits, some appointments have been saved by requesting a GP to consider prescribing certain medications. This data is supported by a 7% reduction in ambulances to the ED department and in December 2018, 177 calls had been diverted to the DHC supporting prevention of 73 ED attendances and 113 ambulance call outs.

These figures indicate that care home residents who may previously have been directed to ED for non-emergency cases, possibly causing distress and poorer outcomes, can remain in a comfortable place and be given tailored advice.

Better experience – The DHC has successfully brought care closer to home, avoiding hospital admissions and improving the healthcare experience of care home residents. Whilst some patients will still require a visit to A&E, many residents in care homes benefitted from the service and did not require a hospital visit. Patients with dementia often take days to re-adjust when taking out of their familiar surroundings and now staff can access advice and guidance from their place of residence. Patients are receiving the right care in the best place for them. Patients, carers and families have found the service very accessible and easy to use. Feedback is collected regularly via the Friends and Family test. Complementary emails from care home staff include:

“The Digital Health is excellent and with hindsight I do not know how we ever managed without it. Your team are fantastic, quick, knowledgeable, caring, considerate, basically second to none. Our staff team, myself and residents are treated with the utmost respect and dignity.”

“We feel the service is fabulous it’s made such a difference to our home. The support we get from all the team is great we could not do without, this service it’s great to know we have that support when we need it to ensure our residents are treated as soon as possible with their health needs.”

“I have always found and still do, that the Digital health service is a valuable tool in ensuring residents needs are met quickly and appropriately. Care staff feel they now have a safety net when they have concerns about a resident’s health, that can be dealt with immediately without having to wait until the GP is available.”

Better use of resources – National savings of £875,000 have been achieved as of October 2018. Care home staff would previously attend the ED department with patients if relatives were unable to attend – the service has achieved a saving of approximately 7,872 care home staff hours.

Challenges and lessons learnt for implementation

It is key to have people with the correct outlook and attitude to driving innovation and services, especially when cross boundary working is applied. Having a positive attitude and belief in what you are doing is also key, along with relationship building and good communication.

Start slowly and test the concept at small scale first. A supportive working environment has been created with regular peer review – the team have regular one to ones to discuss the needs of the service and their educational needs.

When the idea was initially presented to the care home managers’ forum it was not well received and there were some homes that did not want the service. There was focus on getting the worst performing homes on board first to show the benefits, however the nurse advised the project would only work if colleagues were committed to possible success.

For more information contact

Peter Grace
Emergency Nurse Practitioner and Clinical Nurse Lead for Digital Health
Tameside and Glossop Integrated Care NHS Foundation Trust
peter.grace@tgh.nhs.uk