This report summarises the methodology and the outcome of a pilot project designed to reduce the number of elderly patients admitted to hospital from nursing homes. It suggests that enhanced out of hours care by GPs can improve the experience of patients (and their relatives) and reduce costs by limiting emergency admissions to those for whom there is no alternative to immediate hospital treatment.
Nursing home residents frequently have a number of long-term conditions, some of which will be in end stage. These patients require a generalist medical approach, rather than a set of specialists for each condition. Their doctors require knowledge and expertise in managing the problems of co-morbidity, dementia, frailty and end-of-life care, and making judgements on medications that will maximise benefits.
During the in-hours period, staff at nursing homes have access to the patient’s own registered GP who is likely to know the resident and have full access to their medical history. In the out-of-hours period, staff can call the locally commissioned GP’s out-of-hours service.
The standard of care provided by these services is acknowledged to be very variable. Staff attending may have limited skills in geriatric medicine, with limited access to medical records. They also may be under time-pressure, with a long list of visits to be made. Sometimes the resident’s preferred end-of-life care plan may be unavailable or incomplete.
In these circumstances the easy option may be to admit the ill resident to the local hospital. In addition the potential delay in securing the attendance of an out-of-hours GP may encourage the NH staff to bypass this system and simply call 999 for an emergency ambulance.
Such an admission may not be in the best interests of the resident. They may simply be nearing the end of their life, and need good palliative end-of-life care, which can readily be provided in a nursing home with support from the GP services. Residents who are admitted inappropriately may cause logistic problems for the A&E Department, and in a worst case scenario the patient may die in A&E while awaiting a hospital bed.
This project was carried out in the area of north-east Hampshire and the adjoining areas of Surrey and Berkshire, served by Frimley Park Hospital Foundation Trust. The local OOH service is Frimley Primary Care Service (FPCS), which operates from the hospital’s out-patient department.
FPCS was formerly a GP Cooperative, but is now a community benefit society, and is staffed by local GPs, practice nurses, and recently qualified GP registrars, all of whom work locally and are aware of the local NHS Services.
Over the last year the A&E Department has documented a large increase in nursing home staff calling 999 for their residents who are significantly unwell, and it has been apparent that many of these are at the end of their lives and should have been cared for within the NH.
This led to a pilot project, funded by the hospital, with FPCS agreeing to provide enhanced GP care and make this readily available to NH staff, in an attempt to reduce the large numbers of inappropriate emergency admissions via 999 calls from nursing homes.
Two additional GPs were recruited with an interest in care of older people. They covered the period from 18.30 – 22.00 Monday to Friday and 10.00 – 18.00 on Saturday and Sunday.
Visits were made at the request of the staff in nursing and residential homes, and also to older patients at home who requested OOH GP care, especially if they seemed to have complex needs.
Where the 999 Ambulance Services had been summoned initially to an elderly person and the paramedic on the scene felt that admission was not needed, one of the two designated GPs attended.
After assessment, where possible, on-going care was provided without admission to hospital, with appropriate review by the patient’s own GP, or by referral to the geriatric day hospital or falls clinic.
A visit which was deemed by the attending doctor to have avoided an admission, was logged as such and reviewed by one of the medical directors of FPCS, a senior experienced GP. He sought to provide an objective opinion based on many years experience of working with the OOH service, as to whether the admission had been prevented by the ‘enhanced care’ provided by this project, or whether ‘usual care’ would have delivered a similar outcome.
Over the six-month study a total of 397 visits were made by the designated GPs to elderly residents of nursing homes, residential care homes, and to some in their own homes. On review of the case notes by the medical director, it was felt that 54 admissions to hospital were prevented by the additional time, skills or resources available to these two designated GPs (table 1).
Other prevented admissions were deemed to have been within the scope of the standard service and competence of the OOH service doctors.
Table 2 shows the admissions deemed to have been prevented once broken down into diagnostic groups. Urological diagnoses and chest infections form the largest groups where hospital admissions were prevented. Although ‘usual OOH care’ would have prevented some admissions, we found that in all diagnostic areas there were additional cases where the medical director considered that the ‘enhanced care’ had prevented hospital admission.
In cases with a urological diagnosis 83% (20 out of 24) were considered to have been attributed to the enhanced care from the two designated doctors.
Since the 2003 GP Contract, GPs have ceased to have responsibility for OOH care, and this has been commissioned by PCTs. The quality and effectiveness of the OOH care provided has been criticised following recent well-publicised incidents, and the publication of General Practice out of hours services; Project to consider and assess current arrangements, which documents the variability of standards around the country. OOH services are often busy and are designed to give urgent and immediate care to patients needing primary care in the OOH period. Many elderly patients in nursing homes or in their own homes require a home visit, but the visiting GP may be constrained by limited time and resources. Some staff in NHs have apparently felt that a 999 call is the best way to seek medical help, rather than contacting the local OOH service at FPCS.
Both of these factors tend to increase the conveyance of elderly patients to the A&E department, and once there it is much more difficult to avoid an admission to hospital, which is costly and may not be in the patient’s best interests.
The aim of this pilot study was to provide ‘enhanced care’ to these elderly patients in the NH where they now live or in their own homes. Enhanced Care was to be provided by two designated GPs with appropriate experience in both primary care and geriatric medicine. As supernumerary doctors at the OOH service, they could allow more time for their assessment, and they had additional experience which enabled them to use resources not normally considered appropriate by GPs.
This is most clear in cases with a urological diagnosis. This group mainly comprised of patients thought to have a significant urological infection, or those with catheter problems. Those with infections were often confused, dehydrated, or unable to take oral antibiotics. The ‘enhanced service’ GPs were able to use their experience and knowledge to utilise parenteral antibiotics, which is not normally considered by ‘usual care’ doctors. They also tended to use subcutaneous fluids, and had sufficient time to instruct the NH staff in supervising this care. They were available on the mobile phone to give subsequent advice or to re-visit.
Catheter problems are normally dealt with during the working day by district nurses and there is limited availability of nursing services in the OOH period. Many GPs have become de-skilled in dealing with catheter problems. The ‘enhanced care’ GPs had the time and resources to manage many catheter problems at home, thereby preventing an unnecessary admission.
Clearly the urological diagnostic cases are shown to be the area with most potential for improved care in the OOH period. The use of parenteral antibiotics and subcutaneous fluids in appropriate cases and with the necessary training will prevent hospital admissions. Catheter problems are also the cause of many preventable admissions, and a greater availability of nurses in the OOH period would save many hospital attendances.
Having sufficient time to assess and deal with the problem, and without the pressure of a long list of visits to be done, was another major factor in allowing the ‘enhanced care’ GPs to prevent more admissions to hospitals. This was particularly seen in the area of palliative care and mental health problems.
Our assessment of whether or not an admission had been avoided was subjective, but it relied on the experience of the staff concerned. Many of these were cases where it was felt that the staff or relatives were initially expecting an admission, or had rung 999 or were planning to do so. The availability of an early visit and time and resources to deal with the problem were major factors. But our assessment is that the 54 admissions prevented by the effectiveness of the enhanced service offered over the six months of this project.
The overall cost of this enhanced service was £80,000. This includes the employment of the two GPs (as a job-share), additional equipment and other expenses. We have attempted to estimate the financial savings through the prevention of unnecessary attendances at A&E and subsequent admissions to hospital. The tariff costs for an admission vary according to the complexity and length of stay of the case, but using an average figure of £3000 per admission saved, the approximate savings made by preventing 54 admissions is estimated at £162,000.
In addition there were substantial savings through not having to call an ambulance to convey the patient to hospital. The average cost of an ambulance journey is estimated at £145, giving an additional £7,830 of savings.
Unexpectedly, enhanced skills were recognised more often in admissions avoided from locations other than NHs, where the NH GPs with time and expertise were able to set up alternatives to hospital admission in the more difficult circumstances of a frail older patient at home. Potentially these patients were the most cost effective to keep out of hospital as those from NHs are likely to have shorter in-patient stays as they would be able to return to their NH bed without the need to set up additional support.
Finally there is an important benefit that cannot be costed, in keeping elderly patients out of hospital and allowing them to remain in the familiar surroundings of their own home or nursing home. A ‘good death’ is an important goal for many elderly people, and care at home is usually preferred to an acute hospital
This has been a small pilot study, and many of the benefits are subjective or estimated. Nonetheless we do believe that we have shown that if experienced GPs with time, resources and access to appropriate services, are employed by OOH services, then a significant number of unnecessary hospital admissions can be prevented, with significant financial savings to commissioners, and unquantifiable benefits to elderly patients and their relatives.
Teresa Wells is a GP with interest in geriatric medicine, Stephen Linton is medical director of Frimley Primary Care Service and Susan Paterson is chief executive of Frimley Primary Care Service