‘‘They already have a bed…They already have a bed…

let them stay in theirslet them stay in theirs’’

Ann Conway MSc (ACP) BSc (Hons) DN RGNAnn Conway MSc (ACP) BSc (Hons) DN RGNCommunity ANP, Ynys MonCommunity ANP, Ynys Mon

October 2015October 2015

Môn Enhanced CareMôn Enhanced CareBackgroundBackground• How The Service BeganHow The Service Began• Population: 71,000 (66,000 registered with a GP)Population: 71,000 (66,000 registered with a GP)• Resources: Single Point of Access SPOAResources: Single Point of Access SPOA

Advanced Nurse Practitioners (1)Advanced Nurse Practitioners (1) Assistant Practitioners (3)Assistant Practitioners (3) Consultant (1)Consultant (1)

Rapid Access ClinicRapid Access Clinic All GP practices signed up All GP practices signed up

Direct Access to Local Authority Re-ablement ServiceDirect Access to Local Authority Re-ablement Service• Rapid Access to investigationsRapid Access to investigations• Hospital Beds (43) in Ysbyty Penrhos Stanley, HolyheadHospital Beds (43) in Ysbyty Penrhos Stanley, Holyhead “ “Hub”Hub”

Môn Enhanced CareMôn Enhanced CareCase PresentationCase Presentation

Patient A, aged 84 married living with spouse.Patient A, aged 84 married living with spouse.Prior to referral to MEC totally independent, no socialPrior to referral to MEC totally independent, no socialservice input.service input.• Presenting Complaint and Past Medical HistoryPresenting Complaint and Past Medical History• Current MedicationCurrent Medication• FindingsFindings• Differential DiagnosisDifferential Diagnosis• Management PlanManagement Plan• Review by ANPReview by ANP• Review at rapid access clinic and COTEReview at rapid access clinic and COTE• OutcomeOutcome

ReferralReferral

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

Presenting Complaint and Presenting Complaint and Past Medical HistoryPast Medical History

Presenting ComplaintPresenting Complaint ‘‘Feeling rotten’ Increased lethargy, increasedFeeling rotten’ Increased lethargy, increasedshortness of breath past 2 weeks, reducedshortness of breath past 2 weeks, reducedappetite, unsteady on feet, ‘slurred speech’appetite, unsteady on feet, ‘slurred speech’previous day and cough after fluidsprevious day and cough after fluids..

Past Medical HistoryPast Medical History

Macular degenerationMacular degeneration

Current MedicationCurrent Medication

OTCOTC• Garlic TabletsGarlic Tablets• Cod liver oilCod liver oil

• Ex Smoker (gave up several years ago)Ex Smoker (gave up several years ago)• Enjoys occasional glass of whiskyEnjoys occasional glass of whisky• No known AllergiesNo known Allergies

FindingsFindings

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

FINDINGSFINDINGS

BloodsBloods• U/Es (Istat) normalU/Es (Istat) normal• CRP 76 (<5)CRP 76 (<5)• WCC NormalWCC Normal

Problem List and Problem List and Differential DiagnosisDifferential Diagnosis

ProblemsProblems• Increased lethargyIncreased lethargy• Productive CoughProductive Cough• ConfusionConfusion• UnsteadinessUnsteadiness• Slurred SpeechSlurred SpeechDifferential DiagnosisDifferential Diagnosis• Chest InfectionChest Infection• ? Stroke ? Stroke

Management PlanManagement Plan

• Discussed with COTE and GPDiscussed with COTE and GP• DoxycyclineDoxycycline• Clarithromycin Clarithromycin • AspirinAspirin• COTE arranged CT scan and Chest Xray (Within one COTE arranged CT scan and Chest Xray (Within one

week)week)

ReviewReview

• ANPANP• Improving: Apyrexial, SPO2 96%, P84Improving: Apyrexial, SPO2 96%, P84• Discussed at virtual ward roundDiscussed at virtual ward round• CT Scan : Confirmed StrokeCT Scan : Confirmed Stroke• Chest Xray: Confirmed chest infectionChest Xray: Confirmed chest infection

OutcomeOutcome

• Responded well to oral antibioticsResponded well to oral antibiotics• Remained on Aspirin for 2 weeks then commenced Remained on Aspirin for 2 weeks then commenced

clopidrogel and statinclopidrogel and statin• 24 hour ECG (at home by Mec) No AF24 hour ECG (at home by Mec) No AF

OutcomeOutcome

Patient remained at home, hospital admission avoided.Patient remained at home, hospital admission avoided.Patient discharged from MEC with GPs consent. Patient discharged from MEC with GPs consent. Followed up in stroke clinicFollowed up in stroke clinic

No of visits:No of visits: GP 2GP 2ANP 6ANP 6S/N 2S/N 2AP 6AP 6DN 0DN 0COTE 1COTE 1

Môn Enhanced CareMôn Enhanced CareCase PresentationCase Presentation

Patient B, aged 89 years lives, with daughter. Prior toPatient B, aged 89 years lives, with daughter. Prior toreferral to MEC there was no input from other disciplines.referral to MEC there was no input from other disciplines.Presenting Complaint and Past Medical HistoryPresenting Complaint and Past Medical History• Current MedicationCurrent Medication• FindingsFindings• Differential DiagnosisDifferential Diagnosis• Management PlanManagement Plan• Review by ANPReview by ANP• OutcomeOutcome

ReferralReferral

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

Presenting Complaint and Presenting Complaint and Past Medical HistoryPast Medical History

Presenting ComplaintPresenting Complaint ‘‘Gone off legs’ Gone off legs’

Increased lethargyIncreased lethargy

DyspnoeaDyspnoea

Past Medical HistoryPast Medical History

Aortic StenosisAortic Stenosis

Heart FailureHeart Failure

AsthmaAsthma

Generalised OsteoarthritisGeneralised Osteoarthritis

Current MedicationCurrent Medication

• Aspirin 75mg dailyAspirin 75mg daily• Omeprazole 20mg dailyOmeprazole 20mg daily• Furosemide recently increased to 80mgFurosemide recently increased to 80mg• Digoxin 125mcgDigoxin 125mcg• DuoResp Spiromax (inhaler twice daily)DuoResp Spiromax (inhaler twice daily)• ParacetamolParacetamol

• Allergies:Clarithromycin, erythromycin, tetracycline, codeineAllergies:Clarithromycin, erythromycin, tetracycline, codeine• Never smoked, no alcoholNever smoked, no alcohol

FindingsFindings

Review of Systems:Review of Systems:In bed past 24 hours ‘my legs have gone’. Breathlessness on exertion,In bed past 24 hours ‘my legs have gone’. Breathlessness on exertion,using 3 pillows. Productive cough past few days. No chest pain. using 3 pillows. Productive cough past few days. No chest pain. Recent blisters on legs ‘weeping oedema’ Reduced appetite. No nauseaRecent blisters on legs ‘weeping oedema’ Reduced appetite. No nauseaor vomiting. Joint stiffness. No recent fallsor vomiting. Joint stiffness. No recent fallsOn ExaminationOn Examination Looks unwell, frail, pale.Looks unwell, frail, pale.T35.2, RR 26, SPO2 94% on air. BP 160/80 . P 68 irreg. JVP notT35.2, RR 26, SPO2 94% on air. BP 160/80 . P 68 irreg. JVP notelevated. Bilateral ankle oedema. Kyphosis. Coarse crackles left baseelevated. Bilateral ankle oedema. Kyphosis. Coarse crackles left baseof lung. Dull to percussion. Abdomen soft and nonof lung. Dull to percussion. Abdomen soft and nontender. O/A both knees. Evidence of PVD both feet poorly perfused.tender. O/A both knees. Evidence of PVD both feet poorly perfused.

FindingsFindings

Blood resultsBlood results Istat Istat• Sodium 116 (133-146)Sodium 116 (133-146)• Other renal function normalOther renal function normal• Other Blood results (Within the Hour)Other Blood results (Within the Hour)• CRP 30CRP 30

Problem List and Problem List and Differential DiagnosisDifferential DiagnosisProblem list:Problem list:• ‘‘Gone off Legs’Gone off Legs’• Productive coughProductive cough• Increased LethargyIncreased Lethargy

Differential Diagnosis:Differential Diagnosis:• Hyponatraemia (low sodium)Hyponatraemia (low sodium)• Chest InfectionChest Infection

Management PlanManagement Plan

• Stop furosemideStop furosemide• Stop omeprazoleStop omeprazole• Restrict fluid intake to one litre/24 hours Restrict fluid intake to one litre/24 hours • Discussed findings with GPDiscussed findings with GP• Commence Amoxicillin 500mg TDSCommence Amoxicillin 500mg TDS• Register on OOH data baseRegister on OOH data base• Glide-about commode requestedGlide-about commode requested

REVIEWREVIEW

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

ReviewReview

Weekend supported by DN Weekend supported by DN Telephone advice from OOHTelephone advice from OOHANP : slight improvement, nausea resolvedANP : slight improvement, nausea resolvedSodium 122Sodium 122Referred to physioReferred to physioReferred to OTReferred to OT2 days later agreed referral for Re-ablement2 days later agreed referral for Re-ablement

OutcomeOutcome

• Continued to improve, mobilising slowly around Continued to improve, mobilising slowly around house.house.

• Sodium returned to normal rangeSodium returned to normal range• Following discussion at virtual ward roundFollowing discussion at virtual ward roundomeprazole and low dose furosemide re introduced.omeprazole and low dose furosemide re introduced.

OutcomeOutcome

Patient remained at home, hospital admission avoided.Patient remained at home, hospital admission avoided.No of visits:No of visits:

GP 3GP 3ANP 11ANP 11AP 13AP 13DN 2DN 2Physio 3, Physio 3, OT 1OT 1Re-ablement Re-ablement

OOH Phone support x 2OOH Phone support x 2

Môn Enhanced CareMôn Enhanced CareThe VisionThe Vision• Build on existing strengthsBuild on existing strengths

• Based in Social Services : integrated workingBased in Social Services : integrated working

• Build upon the Multidisciplinary Approach ( GP, Community Nursing, OTs, Physios, Build upon the Multidisciplinary Approach ( GP, Community Nursing, OTs, Physios, Re ablement, Social Worker, Older Peoples Mental Health Services, WAST, Third Re ablement, Social Worker, Older Peoples Mental Health Services, WAST, Third Sector )Sector )

• Turn Around from YG (AMAU and A/E)Turn Around from YG (AMAU and A/E)

• Step DownStep Down

Môn Enhanced CareMôn Enhanced CareChallengesChallenges

• Resources:Resources:• Time: Hours 9-5 Mon-Fri -move towards 24hrs and 7 day workingTime: Hours 9-5 Mon-Fri -move towards 24hrs and 7 day working• Travelling: rural area. (However now central)Travelling: rural area. (However now central)• Financial Support : Developed and maintained on existing resources Financial Support : Developed and maintained on existing resources

through role re design, needs investment to develop furtherthrough role re design, needs investment to develop further• Education: (ongoing professional development)Education: (ongoing professional development)• Change of culture to keep patient at homeChange of culture to keep patient at home• Workforce development: Extension of Assistant Practitioner roleWorkforce development: Extension of Assistant Practitioner role Training of new ANPs and Care of the Elderly ConsultantsTraining of new ANPs and Care of the Elderly Consultants• Interface with existing community nursing and the wider MDTInterface with existing community nursing and the wider MDT• Clinical: Extend home IVs and Sub cut fluidsClinical: Extend home IVs and Sub cut fluids

Môn Enhanced CareMôn Enhanced CareActivity ReportActivity Report

• 11stst August 2014 to 31 August 2014 to 31stst July 2015 – a total of 201 July 2015 – a total of 201 cases (197 of which were defined as being cases (197 of which were defined as being exclusively Enhanced care – all 201 have been exclusively Enhanced care – all 201 have been included in the following data)included in the following data)

Case starts by practice (anonymised)

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12

Number of case starts by referring practice

<655% 65-74

7%

75-8433%

>8555%

Age breakdown

Existing ConditionsExisting Conditions

Deterioration in General ConditionDeterioration in General Condition 5959Decreased MobilityDecreased Mobility 5151BlankBlank 2525Chest InfectionChest Infection 2424Heart FailureHeart Failure 2323Exc of COPDExc of COPD 2121DiabetesDiabetes 2020AFAF 1919Acute confusionAcute confusion 1818OtherOther 184184Grand TotalGrand Total 400400

Diagnosis GroupDiagnosis Group

CountCount PercentagePercentageOtherOther 123123 61.2%61.2%CardiovascularCardiovascular 2626 12.9%12.9%RespiratoryRespiratory 2020 10.0%10.0%AlzheimerAlzheimer 88 4.0%4.0%Atrial FibrillationAtrial Fibrillation 77 3.5%3.5%BlankBlank 66 3.0%3.0%DiabetesDiabetes 33 1.5%1.5%NeurologicalNeurological 33 1.5%1.5%StrokeStroke 33 1.5%1.5%Other symptoms and signs 2 Other symptoms and signs 2 1.0%1.0%

Outcome Count

Admitted to hospital 54

Back to previous function 124

Deceased 5

Placed in nursing / residential home 8

Referred for additional community services 10

Grand Total 201

Number of Visits and Days on ServiceNumber of Visits and Days on Service

Number of VisitsNumber of VisitsSum of Number of ANP visitsSum of Number of ANP visits 558558Sum of Number of AP's visits Sum of Number of AP's visits 770770

Days on ServiceDays on ServiceCount of Referrals Count of Referrals 201201Total days on service Total days on service 29032903Average days on serviceAverage days on service 14.914.9

The CostThe Cost

The cost per patient of a two weekThe cost per patient of a two weekEnhanced Care at Home episode wasEnhanced Care at Home episode wasestimated as £762, which is a third of theestimated as £762, which is a third of thecost of a two week hospital stay (£2,854). cost of a two week hospital stay (£2,854).

Responses from Service UsersResponses from Service Users

• This service, in my opinion, is excellent. It allows the patient to be This service, in my opinion, is excellent. It allows the patient to be home instead of in hospital. home instead of in hospital.

• Without this service I would have been admitted to hospital, which Without this service I would have been admitted to hospital, which would have caused me considerable distress and undoubtedly would have caused me considerable distress and undoubtedly exacerbated my condition. exacerbated my condition.

• This has prevented so many admissions to hospital and improved the This has prevented so many admissions to hospital and improved the quality of life of the residents at our Care Home. quality of life of the residents at our Care Home.

• Very impressive. Mother was greatly reassured by all members of Very impressive. Mother was greatly reassured by all members of staff, and with their assistance made a remarkable recoverystaff, and with their assistance made a remarkable recovery

THANK YOUTHANK YOU

Any Questions?Any Questions?