Joint working between Hampshire Ambulance and the rapid response team (RRT) has developed a project called Perfict Partners (Patient Electronic Referral for Intermediate Care Teams) to improve the care of older people in the community.
The project has been successful in ensuring older people who dial 999 but do not require hospital admission receive comprehensive follow-up care. The work is contributing to the long-term conditions agenda by finding patients who are experiencing a decline and require health and/or social care support to meet their needs. The challenge was to develop a single point of access to a comprehensive range of services.
National demand on ambulance services is increasing annually but only 10% of 999 calls are reporting life-threatening emergencies. (DH, 2005a). Where there is not significant injury, subsequent treatment can be provided in the community. Ambulance services need to be utilised according to need to ensure that they can respond appropriately to actual medical emergencies.
Unpublished data in Hampshire shows that about 45,000 patients annually are treated at scene and not conveyed to hospital. Ambulance crews wanting to refer patients on for follow-up frequently need to navigate complex referral systems. This often results in a less than optimum outcome for the patient. The key to success, especially for older people, is to ensure a timely and comprehensive response to their needs.
A one-month pilot of clinical triage within 24 hours of all patients who dialled 999 from home but did not attend hospital attendance demonstrated significant improvements for patients.
Patients were contacted by phone by the RRT and asked if they would like a home visit if needed. Only two patients refused. The RRT is an assessment and rehabilitation team that provides a crisis intervention service.
During the pilot it was found that a third of triaged patients over eighty had not input from health or social services. Fifty per cent of the 999 calls from patients over 65 were for falls. Although a fall was the reason given for the call, the causes were many and varied. The RRT provided environmental assessment and full falls assessment. Rehabilitation was provided where needed, together with the supply of basic equipment.
The many underlying causes of falls necessitated the development of various care pathways. An urgent pathway was developed to the consultant geriatrician for patients with complex reasons for their falls.
Patients could also be referred urgently to their district nurse, specialist nurses, mental health services, GP, social care services and community therapy services. An admission pathway to a local community hospital was also developed for those patients requiring inpatient care and/or rehabilitation.
Addressing the underlying causes of falls is key to preventing premature dependency. Fifty per cent of people experiencing a hip fracture lose the ability to live independently (National Osteoporosis Society, 2002). Timely intervention can avoid premature dependency.
Seven per cent of the referrals for a fall were as the result of underlying diabetes. Many of these patients are suitable for referral for Level 1 or 2 case management for long-term conditions.
Level 1 involves education and support to facilitate the patient managing their condition more proactively. Level 2 indicates that the patient is at high risk of developing complications and would benefit from the assistance of the multidisciplinary team (DH, 2005b). Appropriate referrals can be made by the RRT to facilitate this care.
Issues in practice require clinical teams to be creative and develop solutions to problems in the best interests of patients. A single point of access has meant that patients receive the follow-up care they need and appropriate referral for case management.
In terms of a national driver to match ambulance response to need, falls are of major concern. If a patient is supported appropriately on the first occasion they dial 999, then it is likely that further 999 calls are not necessary. This allows emergency vehicles to respond to life-threatening incidents in a more timely way.
The success of the this project was due to the commitment of the RRT and Hampshire Ambulance Service. It is a win-win situation for patients, the team and the ambulance service alike. The project is now embedded in everyday practice.
The project received the Hampshire and Isle of Wight Strategic Health Authority Award for partnership working in 2005 and was a finalist in the 2006 NT Awards in the teamworking category.
Contact: Jacqueline Metcalfe, consultant nurse for older people, North Hampshire Hospital and Hampshire PCT
DH (2005a) Taking Healthcare to the Patient; Transforming NHS Ambulance Services.London: The Stationery Office.
DH (2005b) Supporting People with Long Term Conditions; Liberating the Talents of Nurses who care for People with Long Term Conditions.London: The Stationery Office.
Metcalfe, J. (2006) Enhancing the care of older people in the community. Nursing Standard20(52): 40-43.
National Osteoporosis Society (2002) Primary Care Strategy for Osteoporosis and Falls.Bath: National Osteoporosis Society.