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‘They already have a bed… let them stay in theirs ’

Learn about the Môn Enhanced Care program, providing rapid access to investigations and avoiding hospital admissions for elderly patients with complex medical needs. Case presentations showcase the success of this innovative approach.

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‘They already have a bed… let them stay in theirs ’

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  1. ‘They already have a bed…let them stay in theirs’ Ann Conway MSc (ACP) BSc (Hons) DN RGN Community ANP, Ynys Mon October 2015

  2. Môn Enhanced CareBackground • How The Service Began • Population: 71,000 (66,000 registered with a GP) • Resources: Single Point of Access SPOA Advanced Nurse Practitioners (1) Assistant Practitioners (3) Consultant (1) Rapid Access Clinic All GP practices signed up Direct Access to Local Authority Re-ablement Service • Rapid Access to investigations • Hospital Beds (43) in YsbytyPenrhos Stanley, Holyhead “Hub”

  3. Môn Enhanced CareCase Presentation Patient A, aged 84 married living with spouse. Prior to referral to MEC totally independent, no social service input. • Presenting Complaint and Past Medical History • Current Medication • Findings • Differential Diagnosis • Management Plan • Review by ANP • Review at rapid access clinic and COTE • Outcome

  4. Referral ‘Patient did not want to go to hospital’ Time of Referral :8.45 Time of Response: 10.55. HCA: Baseline obs and ECG. ANP: History and Clinical Examination Differential diagnosis. Bloods are taken for: FBC, U/Es, LFTs, Bone Profile, TFT, Glucose ISTAT (Renal function immediate results) HCA takes bloods to YG.

  5. Presenting Complaint and Past Medical History Presenting Complaint ‘Feeling rotten’ Increased lethargy, increased shortness of breath past 2 weeks, reduced appetite, unsteady on feet, ‘slurred speech’ previous day and cough after fluids. Past Medical History Macular degeneration

  6. Current Medication OTC • Garlic Tablets • Cod liver oil • Ex Smoker (gave up several years ago) • Enjoys occasional glass of whisky • No known Allergies

  7. Findings Review of Systems: Cough, expectorating yellow sputum, also cough after fluids. Occasional wheeze. No chest pain. Reduced appetite. Weight loss 4 kgs in past two weeks. Previous day h/o confusion, unsteadiness, ‘slurred speech’ lasted 2 hours. Increased lethargy On Examination Pink, no cyanosis. RR28, SPO2 93% on air, T37.6 BP 126/70 lying, 100/70 standing. Coarse crackles MZ and base right, some exp wheeze. Element of pvd (both feet poorly perfused). Orientated to time and place, did not know current year. Unable to identify number of fingers held up, blowing cheeks out not symmetrical. Unable to co-ordinate finger to nose right hand, power reduced right hand.

  8. FINDINGS Bloods • U/Es (Istat) normal • CRP 76 (<5) • WCC Normal

  9. Problem List and Differential Diagnosis Problems • Increased lethargy • Productive Cough • Confusion • Unsteadiness • Slurred Speech Differential Diagnosis • Chest Infection • ? Stroke

  10. Management Plan • Discussed with COTE and GP • Doxycycline • Clarithromycin • Aspirin • COTE arranged CT scan and Chest Xray (Within one week)

  11. Review • ANP • Improving: Apyrexial, SPO2 96%, P84 • Discussed at virtual ward round • CT Scan : Confirmed Stroke • Chest Xray: Confirmed chest infection

  12. Outcome • Responded well to oral antibiotics • Remained on Aspirin for 2 weeks then commenced clopidrogel and statin • 24 hour ECG (at home by Mec) No AF

  13. Outcome Patient remained at home, hospital admission avoided. Patient discharged from MEC with GPs consent. Followed up in stroke clinic No of visits: GP 2 ANP 6 S/N 2 AP 6 DN 0 COTE 1

  14. Môn Enhanced CareCase Presentation Patient B, aged 89 years lives, with daughter. Prior to referral to MEC there was no input from other disciplines. Presenting Complaint and Past Medical History • Current Medication • Findings • Differential Diagnosis • Management Plan • Review by ANP • Outcome

  15. Referral ‘Patient doesn’t want to be admitted to hospital’ Time of Referral : 9.30pm Time of Response: 11.20. HCA baseline obs and ECG. ANP: History and Clinical Examination Differential diagnosis. Bloods are taken for: FBC, U/Es, LFTs, Bone Profile, TFT, Glucose ISTAT (Renal function immediate results) HCA takes bloods to YG.

  16. Presenting Complaint and Past Medical History Presenting Complaint ‘Gone off legs’ Increased lethargy Dyspnoea Past Medical History Aortic Stenosis Heart Failure Asthma Generalised Osteoarthritis

  17. Current Medication • Aspirin 75mg daily • Omeprazole 20mg daily • Furosemide recently increased to 80mg • Digoxin 125mcg • DuoRespSpiromax (inhaler twice daily) • Paracetamol • Allergies:Clarithromycin, erythromycin, tetracycline, codeine • Never smoked, no alcohol

  18. Findings Review of Systems: In bed past 24 hours ‘my legs have gone’. Breathlessness on exertion, using 3 pillows. Productive cough past few days. No chest pain. Recent blisters on legs ‘weeping oedema’ Reduced appetite. No nausea or vomiting. Joint stiffness. No recent falls On Examination Looks unwell, frail, pale. T35.2, RR 26, SPO2 94% on air. BP 160/80 . P 68 irreg. JVP not elevated. Bilateral ankle oedema. Kyphosis.Coarse crackles left base of lung. Dull to percussion. Abdomen soft and non tender. O/A both knees. Evidence of PVD both feet poorly perfused.

  19. Findings Blood resultsIstat • Sodium 116 (133-146) • Other renal function normal • Other Blood results (Within the Hour) • CRP 30

  20. Problem List and Differential Diagnosis Problem list: • ‘Gone off Legs’ • Productive cough • Increased Lethargy Differential Diagnosis: • Hyponatraemia (low sodium) • Chest Infection

  21. Management Plan • Stop furosemide • Stop omeprazole • Restrict fluid intake to one litre/24 hours • Discussed findings with GP • Commence Amoxicillin 500mg TDS • Register on OOH data base • Glide-about commode requested

  22. REVIEW Next working day: • ANP Review • Remains frail and unwell • Nausea discussed with GP antiemetic issued. • Further blood tests • Commode in place

  23. Review Weekend supported by DN Telephone advice from OOH ANP : slight improvement, nausea resolved Sodium 122 Referred to physio Referred to OT 2 days later agreed referral for Re-ablement

  24. Outcome • Continued to improve, mobilising slowly around house. • Sodium returned to normal range • Following discussion at virtual ward round omeprazole and low dose furosemide re introduced.

  25. Outcome Patient remained at home, hospital admission avoided. No of visits: GP 3 ANP 11 AP 13 DN 2 Physio 3, OT 1 Re-ablement OOH Phone support x 2

  26. Môn Enhanced CareThe Vision • Build on existing strengths • Based in Social Services : integrated working • Build upon the Multidisciplinary Approach ( GP, Community Nursing, OTs, Physios, Re ablement, Social Worker, Older Peoples Mental Health Services, WAST, Third Sector ) • Turn Around from YG (AMAU and A/E) • Step Down

  27. Môn Enhanced CareChallenges • Resources: • Time: Hours 9-5 Mon-Fri -move towards 24hrs and 7 day working • Travelling: rural area. (However now central) • Financial Support : Developed and maintained on existing resources through role re design, needs investment to develop further • Education: (ongoing professional development) • Change of culture to keep patient at home • Workforce development: Extension of Assistant Practitioner role Training of new ANPs and Care of the Elderly Consultants • Interface with existing community nursing and the wider MDT • Clinical: Extend home IVs and Sub cut fluids

  28. Môn Enhanced CareActivity Report • 1st August 2014 to 31st July 2015 – a total of 201 cases (197 of which were defined as being exclusively Enhanced care – all 201 have been included in the following data)

  29. Case starts by practice (anonymised)

  30. Existing Conditions Deterioration in General Condition 59 Decreased Mobility 51 Blank 25 Chest Infection 24 Heart Failure 23 Exc of COPD 21 Diabetes 20 AF 19 Acute confusion 18 Other 184 Grand Total 400

  31. Diagnosis Group Count Percentage Other 123 61.2% Cardiovascular 26 12.9% Respiratory 20 10.0% Alzheimer 8 4.0% Atrial Fibrillation 7 3.5% Blank 6 3.0% Diabetes 3 1.5% Neurological 3 1.5% Stroke 3 1.5% Other symptoms and signs 2 1.0%

  32. Number of Visits and Days on Service Number of Visits Sum of Number of ANP visits 558 Sum of Number of AP's visits 770 Days on Service Count of Referrals 201 Total days on service 2903 Average days on service 14.9

  33. The Cost The cost per patient of a two week Enhanced Care at Home episode was estimated as £762, which is a third of the cost of a two week hospital stay (£2,854).

  34. Responses from Service Users • This service, in my opinion, is excellent. It allows the patient to be home instead of in hospital. • Without this service I would have been admitted to hospital, which would have caused me considerable distress and undoubtedly exacerbated my condition. • This has prevented so many admissions to hospital and improved the quality of life of the residents at our Care Home. • Very impressive. Mother was greatly reassured by all members of staff, and with their assistance made a remarkable recovery

  35. THANK YOU Any Questions?

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