Leading change

Sheffield Teaching Hospitals NHS Foundation Trust provides a range of hospital and community services for people in Sheffield, as well as specialist care for patients from further afield via its five teaching hospitals.

The Community Matrons within Integrated Community Care Directorate led the implementation of the ‘Okay to Stay’ plan, which aims to support patients with Long Term Conditions (LTC’s) to avoid unnecessary hospital stays, utilising a simple and accessible patient centred plan and a co-ordinated response from community teams. The plan was co-designed with hospital-based nurses, therapists and medics from across the Trust as well as stakeholders within social care, General Practitioners and Yorkshire Ambulance service. The programme has resulted in better outcomes, experience and use of resources within the local area by addressing unwarranted variation in the form of higher than expected levels of non-elective admissions for service users with long term conditions.

Where to look

Nationally there are approximately 15 million people in England suffering from long term conditions, which account for in the region of 50 per cent of all GP appointments, 64 per cent of all outpatient appointments and over 70 per cent of all inpatient bed days.  Treatment and care for people with long-term conditions is estimated to take up around £7 in every £10 of total health and social care expenditure (Department of Health and Social Care, 2012). Long term conditions are also associated with higher re-admission rates to hospital, with older people also having a longer length of stay than younger patients who are admitted to hospital (Department of Health and Social Care, 2012).

Sheffield Teaching Hospitals Integrated Geriatric and Stroke Medicine (IGSM) directorate identified re-admissions to their wards as an area requiring improvement with a higher number of patients with long term conditions being admitted than expected, despite suitable community services being available. It was this unwarranted variation that led to the establishment of a team to work with patients who have been identified as re-admitted patients to reduce the risk of further admissions.

What to change

The Multidisciplinary team identified that through development of a process whereby patients could have planned, supported care in a community setting without hospital admission they would have better outcomes and experience of the care they receive. Working closely with patient/public representatives to co-design this initiative has shaped the ‘Okay to Stay’ project.

The project was developed with wide stakeholder involvement, led by multi-disciplinary representatives from Sheffield Teaching Hospitals’ Geriatric and Stroke Medicine Wards, Front Door Response Team, Intermediate Care (Beds and Community), Sheffield GP Collaborative (Out of Hours GPs), Community Nursing, Matrons, Pharmacy and Physiotherapy, GP colleagues, Adult Social Care from Sheffield City Council and Yorkshire Ambulance Service.

A multi-agency/multi-professional monthly steering group was formed, with senior nursing leads as well as representatives from the wider multi-disciplinary team, patient representatives and Sheffield Clinical Commissioning Group. As part of this steering group nurses contributed to the development of the ‘Okay to Stay’ plan and via support of the local Citizens Reference Group, this has been has been finalised in an easy to use guide for patients, carers and families to understand.

The ‘Okay to Stay’ plan’s overarching principles is to be patient-centred and therefore care plans are written in partnership with the patient and those relevant in their lives, including family and formal or informal carers.

How to change

The ‘Okay to Stay’ plan aims to support patients with LTC’s to avoid unnecessary hospital stays, utilising a simple and accessible patient centred plan and a co-ordinated response from community teams. The coproduced plan assists patients who can, with support from primary and community services, manage complications of their long term conditions at home. If a hospital admission is necessary, the ‘Okay to Stay’ plan goes with the patient to help reduce length of stay by providing a picture of how the patient manages in their home environment.

Initiating the plan can highlight when a patient lacks the family and carer networks that provide support, giving the community matrons the opportunity to lead on addressing these gaps, through their knowledge of local statutory and third sector services. The plan also includes how a patient manages activities of daily living.

The document can be accessed by urgent care professionals to support their decision making around admissions and the effective care that can be provided within the patient’s home.

The ‘Okay to Stay’ plan is intended to complement nursing care plans by putting the patient at the heart of the plan, for it to be completed with the patient and for the patient. The ‘Okay to Stay’ plans operational implementation and management has been via the Senior Community Matrons. The plan works by using the opportunity of completing the plan to ensure that a patient is fine to stay at home, despite an exacerbation of their health condition. Examples of this might be medications optimisation, review of social support needs or planning for emergency care in the future.

The operational team that supports then use the plan to assess patient needs, identify and implement any support mechanisms and complete the ‘Okay to Stay’ plan with the goal of reducing further hospital admissions.

The programme has been piloted in one site initially.

Adding value

Better outcomes – A total of 36 ‘Okay to Stay’ plans are known to have been completed as part of the pilot. Results have shown that:

• Initiating the plan prompted referrals to other services for 3 patients which was positive.
• Of the 32 patients it has been possible to see that prior to the plan being in place, 69% (22 patients) had experienced at least one emergency admission to hospital, with some having up to 9 admissions, and since the plan has been place this has reduced to only 28% (9 patients). The average length for the plans being in place for these 32 patients is 4.3 months, with the majority having it in place for over 5 months.
• Of the 10 patients who had not been admitted prior to having a plan, all but one has remained at home since initiation of the plan.
• Of the 32 patients, 26 had been in contact with the GP collaborative in the 12 months prior to having an ‘Okay to Stay’ plan, compared to only 11 patients contacting the GP collaborative since having the plan in place. For some patients the frequency of calls has also significantly reduced. One patient going from 5 calls in the 12 months prior, to none in the 6 months since having a plan. Another made 4 calls in the previous 12 months, and only 1 in the following 5 months.

Better experience – A total of 5 telephone questionnaires were completed and feedback received has been positive, examples of this have been that patients liked the collaborative way of working, felt part of it and that this has increased their confidence that the paramedics will deal with their circumstances in an informed way.

• “The Plan is a positive force just by its very existence; it opens the door to support and removes the feeling of isolation and helplessness”.
• “I would recommend the plan to anyone in my position. I now feel I know it is ‘Okay to Stay’ and when it is absolutely needed to be admitted to hospital”

Staff experience has also been positive with Community Matrons who have completed the ‘Okay to Stay’ plans with patients finding out new information they may not have previously been aware of via their usual assessment processes. Respondents who had completed a plan described themselves as confident or very confident in doing so with a significant number stating that they learned something new about their patient when completing the plan.

To formalise results a survey of stakeholders was undertaken which showed respondents found the impact of ‘Okay to Stay’ as being positive in the following ways:

• Preventing admission/readmissions to hospital
• Supporting effective discharge home and decision making for health professionals
• Promoting patient independence and enhancing patient centred care
• Improved understanding of patient’s health and social needs
• Supporting multi-disciplinary and cross organisation working

Better use of resources – Pilot results have shown the plan has had a significant impact on the quality of life of patients using the plan and on the use of emergency and urgent care services.

• 41% reduction in emergency hospital admissions – with associated cost savings
• 50% reduction in Out Of Hours GP calls
• The plan costs £240 to implement per patient, per year, compared to a potential saving per patient for just one avoided admission of between £382 – £2,794

Challenges and lessons learnt for implementation

It is important to have wide stakeholder involvement at initial scoping workshops to ensure the aim of the project and what is needed to proceed.

Steering groups are essential and should have a variety of professions, patient groups and voluntary agencies on to encourage the development and operationalising of the plan.

The next steps for the plan are for roll out at a further community nursing service initially and possibly other sites following this.

For more information contact:

• Rebekah Matthews, Integrated Pathway Manager, Okay to Stay Project Lead, Sheffield Teaching Hospital NHS Foundation Trust, Rebekah.Matthews@nhs.net