clinical management where medicine meets management

Published: 08/01/2004, Volume II4, No. 5886 Page 26 27

A model of care for elderly people which has helped nurse practitioners cut admissions and prescriptions through improved risk management is being piloted in the UK by 10 PCT CTs - and being well received, as Carol Lewis explains

Evercare is a US model of care for at-risk older people. Imported to the UK by the Department of Health, it is being piloted by 10 primary care trusts.

The model revolves around an expanded nurse practitioner role. The 'advanced primary nurses', unofficially known as 'Evercare nurses', are in essence care co-ordinators for frail, elderly people.

The US scheme, run by United Health Group, covers more than 60,000 patients. It has cut hospital admission rates by half, reduced the number of prescription drugs taken by patients and has a 97 per cent satisfaction rating from patients' families. It is the second US model to be piloted by PCTs in England - the other being the Kaiser Permanente chronic-disease management programme.

One of the first Evercare nurses in Britain is nurse practitioner registrar Mike Syrat.He is one of two nurses in Airedale PCT Evercare project. Previously a community nurse, he began the Evercare programme in June. So far he has had seven days' training with a US Evercare nurse and spends one day a week on a nurse practitioner degree course at Lancaster University. His nurse mentor, who comes over from the US once a month, has taught him how to conduct a full medical assessment including history taking and physical examination.

He has a caseload of 30 patients who live in their own homes and have been identified as being at high risk of hospital admission. Depending upon the degree of risk, these patients will be visited by Mr Syrat between three times a week and once a month.

His new role is centred on five Cs:

clinical care: assessing and reviewing the patient, monitoring disease progression and identifying early warning signs;

care orchestrator: co-ordinating primary care, secondary care and social services;

communication: acting as a first point of contact for the patient and making sure medical information is shared with GPs, district nurses and, when the patient is in hospital, directly with ward staff;

coaching: educating the patient, carers and family about disease progression; and nchampioning the patient's cause.

Mr Syrat has a GP mentor with whom he spends about an hour a week reviewing cases.He also regularly reviews patients'medication with a local community pharmacist.

He says that feedback from patients and GPs has been good.

There has been criticism in the medical press that the new nurses are taking resources away from district nurses and will ultimately increase the workloads of community nurses and GPs. But this is not Mr Syrat's experience: 'We have been building up trust between ourselves and the GPs. This is a new role and they were initially unsure about what we were going to do. It has been difficult for some people to get their heads round.'

Although it is early days, Mr Syrat loves his new job. 'I feel like I am really making a difference, proactively caring for patients and making a positive difference to their long-term health, ' he says.

He is not the only one who is enthusiastic.Airedale PCT community nursing services director Lyn Wilkinson is about to interview for three to five more nurses to take part in the project. The newly recruited nurses will look after patients in care homes as well as in the community.

Ms Wilkinson says: 'Our initial impression is that the Evercare project has improved the quality of care for frail older people and their carers. It is in line with the single assessment process and offers continuity of care.

The project has the potential to reduce inappropriate admissions to acute hospitals, reduce length of stays and reduce inappropriate polypharmacy, all of which help the PCT to manage resources more effectively.'

She also stresses that the PCT has not diverted attention or resources from district nursing. The plan is to incorporate the Evercare nurses within the 24-hour district nursing teams. They will work with immediate care teams and are a full part of the PCT's plans for reforming emergency care and out-of-hours services.

Head of nursing and professional development at Bristol South and West PCT Sue Field is part of Bristol and South Gloucestershire Evercare project. Thirteen nurses are employed across three PCTs - Bristol South and West, Bristol North and South Gloucestershire. The nurses began working in June and are now drawing up care plans for their patients. They currently have caseloads of about 45 patients, although this is expected to rise to about 55. Project managers from United Health Group visit the PCT about once a week to help push the project forward.

The project is managed by a steering group spanning all three PCTs.On this are representatives from acute services, social services, United Health Group, GPs and mental health. 'The close working with the acute trust has been a catalyst for new developments that wouldn't have happened otherwise, ' says Ms Field. 'For instance, rather than the GP having to wait for a discharge letter, the information via the advanced primary nurse goes into the medical records immediately.

Previously acute, social and primary care services worked together, but it wasn't quite as good as any of us would have liked, ' says Ms Field.

Both Ms Field and Ms Wilkinson believe the Evercare model should be integrated into the PCT and not remain as a project. Both also want the model to be expanded beyond older people to others including sick children or those with chronic diseases.

But not everyone is sold on Evercare. British Geriatrics Society England council chair Dr David Black questions the need to employ Americans when, he says, the Royal College of Physicians, Royal College of Nursing and BGS in the UK presented the same model of care to the DoH three years ago. 'Why waste a hell of a lot of money flying people to and from the US when the wish to do it and the ideas were already here.Why didn't they want to invest in UK knowledge and skills? In general we are welcoming of the philosophy of the Evercare project, but this is tempered by the knowledge that our suggestion didn't even receive a response from the DoH.'

Some commentators have said they believe the DoH is captivated by US models because it believes that healthcare there is managed more aggressively, both to reduce costs and improve health.According to the King's Fund's Jennifer Dixon, the US also offers an experienced, mature managed care market.

However, health minister Stephen Ladyman insists that working with the US companies is about providing patient choice: 'By listening to what people say they want and offering them a range of different types of care provision to meet their needs, PCTs working with these organisations are providing more choice.

This is particularly good news for older people who say they want to live in their own homes and are being offered support and information to make that choice a working reality.'

Key points

'Evercare nurses', based on a US model of an expanded clinical role, are being piloted in 10 trusts.

Pilots report good results in increasing quality of social care.

There has been criticism of diverted resources and unthinking importing of US ideas.

Further information

Evercare www. natpact. nhs. uk/cms/9. php