The West Middlesex Frequent Attenders ProgrammeDr Audrey Ng, Dr Anna Burnside and David MartinWest London Mental Health NHS Trust
Dr Emma Schofield, Dr Michael Beckett andDr Zulfiquar MirzaWest Middlesex University Hospital NHS Trust
Patient A:
72-year-old patient with COPD, attended the ED (A&E?) 479 times in four years.
Presenting complaints:
•COPD requiring O2 therapy but still smoking. Suffers with arthritis.•New prescriptions requested on every attendance for inhalers and
pain relief despite attending 3-4 times a week.•Administers inhalers in the vicinity of his face, despite repeated
attempts at educating him on correct technique. Spacers tried with no success.
Interventions:
•Bio-psycho-social assessment of his needs by a member of the Liaison Psychiatry Team.
•Capacityandneuropsychologicalassessmentrevealeddeficits.Evidence of an anxiety disorder and mild cognitive impairment with some executive dysfunction.
•Social circumstances investigations revealed he was living as a lodger in a multi-occupancy house. Walls were blackened with smoke from cigarettes and incense sticks. Concerns of vulnerability to exploitation from other residents.
Outcome:
•Patient admitted to ward and case conference called which was attended by Social Services, LAS, ED, physicians and Liaison Psychiatry.
•Professionals agreed that his care needs were not being met by his current environment and patient agreed for placement in a nursing home.
•No attendances/admissions since intervention (approx 10 months)
Case study
The West Middlesex Frequent Attenders model
Frequent attenders to WMUH Emergency Department (ED) hadbeenhighlightedasasignificantissue.Aretrospectivereview of the top ten attenders showed that the majority had multifactorial reasons for presentation including medical (87%), alcohol (31%), psychiatric (28%) and social (25%).
Less than 10% had a psychiatric complaint as their presenting feature. Early analysis of the patients suggests that offering a psychosocial assessment regardless of presenting complaint, is a key component in altering their patterns of attendance.
Identification:
•PatientidentifiedbyseniorEDclinicianasafrequentattender.•Proactive and reactive selection methods to be eligible for referral into the
programme. •Psychiatric morbidity is not a requirement.
Collaborative working:
•Full medical assessment by senior ED clinician •Biopsychosocial assessment by a member of the Liaison Psychiatry Team.
Care plan development:
•Care plans that are tailored to the individual’s needs engaging relevant agencies are developed in collaboration with the patient.
•Care plans will be attached to the patient electronic records and automatically prints with their CAS card should the patient reattend.
•This alerts the ED to the care plan to be adhered to.•GPs to receive copies.
Frequent attenders case conference:
•The care plans and progress of each patient in the programme is reviewed and adapted as necessary every two weeks.
•Chaired by Liaison Psychiatry Consultant with senior ED clinicians•Agencies eg, SS, LAS will be invited as required.
Review:
•Patients can be seen in the FA clinic for brief interventions, psychoeducation, engagement work etc.
•Monitoring of subsequent attendances.•Modificationofcareplansandfurtheractionasnecessary.
Proactive multidisciplinary management offrequentattenderssignificantlyreducesattendances, improves patient care and saves money.
West London Mental Health NHS TrustWest Middlesex University Hospital
Patient Number of pre-intervention attendances
Number of post intervention attendances (ongoing data collection)
A 479 in 4 yrs 0
B 69 in 4 yrs 4
C 42 in 2 yrs 0 (but 4 LAS journeys)
D 69 in 4 yrs 0
E 28 in 2 yrs 0
F 25 in 2 yrs 1
G 32 in 2 yrs 0
Total 744 5
Conclusion
Patient Total cost to PCTpre-intervention
Total cost to A&E after tariff paid
A £176,136.07 £8,463.53
B £88,322.09 £1,817.47
C £52,918.83 £1,554.37
D £20,250.34 £3,113.41
E £28,133.00 £917.96
F £61,699.96 £1,755.62
G £23,968.00 £1,081.43
Total £451,482.29 £18,703.79
