The Atlas of Shared Learning

Case study

Older Adults Outreach Team

Leading change

Community Psychiatric Nurses led the development and implementation of a new Older Adults Outreach service at North Staffordshire Combined Healthcare NHS Trust. This service has significantly improved local care pathways as well as positively impacting outcomes, patient and staff experience and use of resources.

Where to look

NHS England highlight that pressures have been building on A&E departments for several years and can increase significantly over winter because of a rise in the number of people admitted to hospital. The NHS Long Term Plan (2019) sets out the response to these challenges including:

  • more joined-up and coordinated in its care;
  • breaking down traditional barriers between care institutions, teams and funding streams to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single, unconnected ‘episode’ of care;
  • more proactive in the services it provides; and,
  • more differentiated in its support offer to individuals.

NHS England’s Winter Grab Guides (2018) highlight that healthcare professionals need to be able to provide a coordinated and proactive service for individuals in need of care. Integrated working with other organisations is essential. Coordinated discharge planning, based on joint assessment processes and shared agreed responsibilities, promotes effective discharge and positive outcomes for patients. By focusing upon decision-making in the right place, high quality care can be provided based upon the principle that assessment for long-term care may not need to take place in hospital.

The Community Psychiatric Nurses at North Staffordshire Combined Healthcare NHS Trust identified an unwarranted variation regarding higher than expected rates of admissions to Royal Stoke University Hospital for older people with mental health concerns and the assessment and management of these individuals once admitted.

What to change

North Staffordshire Combined Healthcare NHS Trust is a provider of mental health, social care and learning disability services in the West Midlands. Following a detailed review of current practice, the Community Psychiatric Nurses identified that bed allocation was varied and lacked consideration at times regarding individual’s needs. Specifically, due to pressures within the system, patients were frequently having their care needs determined less by need and more by availability of services such as bed allocation.

Additionally, the team noted:

  • unmet demand for Older People’s Mental Health (OPMH) beds was at its highest rate, meaning individuals were waiting for periods before they could access inpatient care;
  • patients were sometimes allocated to OPMH beds inappropriately;
  • patient pathways did not take account of the range of community care services available, so staff were defaulting to listing individuals for 24-hour care and not considering options more conducive with promoting independence;
  • higher than expected readmission rates as community care packages didn’t always meet individual needs; and,
  • a reliance upon acute hospital services with proactive measures being underutilised.

This unwarranted variation highlighted that a more individualised approach to assessments of needs was required.

How to change

Community Psychiatric Nurses with the support of senior managers and local commissioners led a pilot of a new Older Adults Outreach service. This service has a remit of working within older people’s services, to support care being delivered and co-ordinated by Community Mental Health Teams, aiming to prevent crisis by using more proactive models of care. Practitioners are enabled to offer an alternative to inpatient admission providing care closer to home. Where an inpatient stay is necessary the Outreach service support ward staff to assess discharge needs and facilitate a safe, timely discharge back into the community.

The nursing leads met with the Triage services at Royal Stoke University Hospital, who generate the listings for assessment beds. To support their understanding of current service provision the team requested and gathered information on:

  • which patients had been identified for transfer to an OPMH assessment bed;
  • a copy of patients’ profile (written by the ward staff/discharge facilitators); and,
  • which wards were patients currently staying in.

Following this, face-to-face assessment of needs were completed with each patient listed. Using their specialist knowledge, the team then discussed their feedback and recommendations with the triage team, including which patients:

  • were safe to return home;
  • require a general assessment bed and removal from the OPMH listing;
  • require OPMH residential assessment;
  • require assessment on shared care mental health/physical health ward;
  • require OMPH nursing assessment bed; and,
  • have acute mental health needs identified and require referral to acute services.

The team are supporting patients to have an accurate assessment of their needs in an appropriate place by bridging the gaps between acute and community care services. In addition, they support staff to work proactively to minimise escalation to crisis points, educating them in best practice and offering an alternative option to hospital admissions. The team also facilitate earlier discharge from the acute hospital wards by providing care and enablement packages to patients, as interim measures, whilst social care community support packages are developed.

The team provide support to patients, carers and services through crisis periods and are embedded as key members of the multi-disciplinary team at Harplands Hospital. Attending weekly ward reviews and meetings to support high quality care provision at the point of transition to community services.

Following the success of the pilot, the nurse leads successfully secured funding to continue and expand the service.

Adding value

Better outcomes – Due to the success of the service, the number of patients waiting for services has reduced significantly meaning individuals are able to access the right care at the time they need it. Patient outcomes have also significantly improved with an increasing number of patients being supported to maximise their independence and return home, as well as access community services appropriately to reduce pressures on emergency services.

Better experience – Improvement in clinical pathways and service offers has improved patient and staff experiences with feedback regarding the service provided all being positive.

Patient and family feedback includes:

  • “Made my journey better”
  • “Couldn’t have done it without you”
  • “Thank you for getting me home”
  • “Thank you for listening”.

Staff feedback has included:

  • “Invaluable service”
  •  “Lowest I’ve ever seen the unmet demand”.

Better use of resources – The work has improved use of resources across acute and community services which has led to cost savings across the providers involved. Specifically, this has been noted in the reduced use of emergency services where people are in crisis, reduced use of 24-hour care as a first option and reduced numbers of patients experiencing delayed discharges from hospital.

Due to the success of the service, the team has received a Trust Recognising Excellence and Achievement in Combined Healthcare (REACH) award in relation to the improvements to patient care that they have made.

Challenges and lessons learnt for implementation

At the time of commencement of the pilot, there was no prior evidence of what this should look like so it is important to understand what services you have in place and what unwarranted variation requires addressing so that you can tailor your approach correctly.

The main challenges faced were to alter the perceptions of others of this process to ensure that the pressures in the system didn’t mean staff lost focus of the patient at the centre of their care.

Use professional judgement, knowledge and expertise available to you to put the needs of the patient first.

For more information contact

Karen Stone
Team Lead
Older Adults Outreach Team
North Staffordshire Combined Healthcare NHS Trust