Governing Body Meeting Thursday 23 rd July 2015 Clinical Navigation Unit Evaluation of the initial pilot phase Dr Marion Radcliffe – Urgent Care Lead Andrea Guest – Operations Director Steve Perks – Deputy Chief Finance Officer

Setting the scene… The CNU is just one key element within the wider RBCCG Transformation Programme

ADT: same day diagnostics; F-ups; hot clinics Clinical Navigation Unit: Primary Care Streaming - signposting/education /empowerment & Urgent Care Enhanced Care: Virtual Ward; incl. Intermediate & Social Care POWCH: Short & medium stay beds: Admission Avoidance & Rehab POWCH & ALEXANDRA POWCH & ALEXANDRA Single Point of Access (Expanded Referral Hub at POWCH for patients and referrers) for Clinical Navigation, Social Prescribing and Proactive Case Management Patient, Family & Carer FOCUS ON CARE AT HOME

Clinical Navigation…

Key Facts… The CNU has been operational since 19 th November The CNU has been operational since 19 th November The CNU pilot runs until 30 th September 2015 and the focus of current activity is: The CNU pilot runs until 30 th September 2015 and the focus of current activity is: o Reduction of ED attendances via re-direction, education and empowerment of patients; o Reduction in preventable admissions through ED via appropriate utilisation of community services.

Purpose of the CNU Pilot Evaluation… To inform the next steps for the CNU beyond the life of the pilot – September 30 th 2015

CNU Attendances All CCGs

CNU Attendances split by RBCCG practices Split per RBCCG practice Split per RBCCG practice Rates per 1,000 Rates per 1,000 How many times patients are seen How many times patients are seen

RBCCG CNU: Nov 14 – May 15 Attendances by Practice rates per 1,000

Actual A&E attendances at The Alexandra Hospital from April 2012 to May 2015

The graphs demonstrate that England, Worcestershire Royal Hospital and the Alexandra Hospital % over the 4 years are each quite different. The graphs demonstrate that England, Worcestershire Royal Hospital and the Alexandra Hospital % over the 4 years are each quite different. The England figures have been stable over the last 3 years at 18%, Worcestershire Royal Hospital has seen peaks every other year with their lower years in between being consistent at 26%. The England figures have been stable over the last 3 years at 18%, Worcestershire Royal Hospital has seen peaks every other year with their lower years in between being consistent at 26%. The Alexandra Hospital saw a peak during January – May 2014 but the 2015 figure is 1% lower than it has been over the previous 3 years. The Alexandra Hospital saw a peak during January – May 2014 but the 2015 figure is 1% lower than it has been over the previous 3 years. Neither nationally nor at Worcestershire Royal Hospital has the trend within the period of January – May 2015 seen a reduction in emergency admissions lower than at any point within the previous 3 years. Neither nationally nor at Worcestershire Royal Hospital has the trend within the period of January – May 2015 seen a reduction in emergency admissions lower than at any point within the previous 3 years.

Had the trend at the Alexandra Hospital followed the same as Worcester Royal Hospital and the conversion rate returned to the pre-peak level (2014) of 29% there would have been 325 admissions more than there actually were. Had the trend at the Alexandra Hospital followed the same as Worcester Royal Hospital and the conversion rate returned to the pre-peak level (2014) of 29% there would have been 325 admissions more than there actually were. Had the Alexandra Hospital followed national trend and remained the same as the previous year, there would have been 2% (453) more admissions. Had the Alexandra Hospital followed national trend and remained the same as the previous year, there would have been 2% (453) more admissions. A reduction of 1% equates to 2 emergency admissions a day and 2% equates to 3 a day. A reduction of 1% equates to 2 emergency admissions a day and 2% equates to 3 a day. The clinical notes review that is detailed in section 7.2 suggests that the CNU is resulting in a reduction of 3 emergency admissions per day. The clinical notes review that is detailed in section 7.2 suggests that the CNU is resulting in a reduction of 3 emergency admissions per day.

RBCCG emergency admissions following CNU implementation

Clinical Notes Review

A retrospective analysis of case notes of patients treated in the CNU to inform and enhance the CNU evaluation process. A retrospective analysis of case notes of patients treated in the CNU to inform and enhance the CNU evaluation process. The case notes for consecutive patients over a 3 day period attending CNU were analysed. The case notes for consecutive patients over a 3 day period attending CNU were analysed. The analysis was used to assess whether the patients would have been admitted if they had attended ED directly rather than being diverted to CNU The analysis was used to assess whether the patients would have been admitted if they had attended ED directly rather than being diverted to CNU Of the 51 consecutive case notes analysed, there were 10 patients identified as admission prevention patients, which equates to 3 patients per day and supports the previous assumptions made re admissions avoidance. Of the 51 consecutive case notes analysed, there were 10 patients identified as admission prevention patients, which equates to 3 patients per day and supports the previous assumptions made re admissions avoidance.

Examples of patients seen within the CNU and admissions avoided (1) Suspected appendicitis Suspected appendicitis – Patient brought in by ambulance; – Seen and assessed by CNU; – Patient had abdominal pain linked with another underlying condition; – Patient referred for review with registered GP; – No further action taken.

Examples of patients seen within the CNU and admissions avoided (2) Paediatric patient from OOH Paediatric patient from OOH – Patient seen and treated within the CNU; – Patient treated for respiratory distress and a fever; – CNU review post treatment to ensure the patient was fit to be sent home; – Patient sent home.

Examples of patients seen within the CNU and admissions avoided (3) Patient presenting with Biliary Colic Patient presenting with Biliary Colic – Patient brought in by ambulance with severe abdominal pain; – Seen and treated within the CNU; – Patient successfully sent home for review with registered GP.

Examples of patients seen within the CNU and admissions avoided (4) Patients presenting with retention of urine Patients presenting with retention of urine – The CNU has reported a number of patients with retention of urine and indwelling catheter problems via the CNU; – All patients have been discharged for GP follow up or trial without catheter (TWOC) clinic reviews.

Examples of patients seen within the CNU and admissions avoided (5) Patient requiring support as a result Patient requiring support as a result of Alzheimer’s of Alzheimer’s – Call to the CNU via the Paramedic Line requesting help as the presenting patient was suffering from Alzheimer’s as her main carer had fallen and fractured his Neck of Femur; – The CNU arranged an Emergency Social Care review; – 24 hour care arranged for the duration of the carers recovery for a stay within a suitable facility.

Stakeholder Views… Analysis of Patient and Public Analysis of Patient and Public views via Friends and Family – set questions; views via Friends and Family – set questions; Simple questionnaires distributed to capture other key stakeholder experience: Simple questionnaires distributed to capture other key stakeholder experience: o Worcestershire Acute Hospitals NHS Trust staff (clinical staff and management staff); o Care UK staff currently working within the CNU; o Local GP practices.

How likely are you to recommend our dept to Friends and Family if they need similar care or treatment?

Actual pilot results compared to July 2014 plan July 2014 – Assumptions GB July 2014 Actual Costs and Savings Range of Potential Savings Full Year Effect

Sensitivity Modelling  Base Case Scenario = uses the evaluation CNU attendances figures and avoided admissions of 3 a day. This would realise savings of £37,000 per month.  Worse Case Scenario = uses SUS attendances but this does not include all SUS data (out of county CCGs are missing as well as CNU telephone contacts) and assumes there are 2 avoided admissions a day. This equates to £7,250 per month and currently delivering at least this level.  Best Case Scenario = uses the evaluation CNU attendances figures with 5 avoided admissions a day. This would realise savings of £84,500 per month.

CNU Opportunities & Developments

CNU Opportunities & Developments (1) Changes to the navigation and triage process; Changes to the navigation and triage process; Developments to the Paramedics Advice Line: Developments to the Paramedics Advice Line: o Countywide potential o Inclusion within the countywide DoS o Inclusion of RBCCG Care Homes; A focus upon the unregistered population; A focus upon the unregistered population; Targeting minority groups including the Polish community. Targeting minority groups including the Polish community.

CNU Opportunities & Developments (2) The introduction of ‘Smart Pathways’ will help to avoid preventable ED attendances; The introduction of ‘Smart Pathways’ will help to avoid preventable ED attendances; Introduction of Paediatric Review Service and opportunity to expand further. Introduction of Paediatric Review Service and opportunity to expand further.

CNU Opportunities & Developments (3) A focus upon access to Primary Care: A focus upon access to Primary Care: o Ensure the availability of appointments at GP Practices where there are high rates of CNU attendance; o Targeted campaigning to educate and empower patients in GP Practices with the "Is A&E for Me” message; o Target GP Practices where there have been reports of Primary Care directing patients to the CNU if they had no appointments.

CNU Opportunities & Developments (4) A dedicated Social Worker – working across the CNU and the ADT from September 2015 – March 2016; A dedicated Social Worker – working across the CNU and the ADT from September 2015 – March 2016; A review of Social Care is also underway which will provide an opportunity to secure the best possible use of Social Care across the NHS RBCCG Transformation Programme. A review of Social Care is also underway which will provide an opportunity to secure the best possible use of Social Care across the NHS RBCCG Transformation Programme.

Key Recommendation EXTEND THE CURRENT CONTRACT FROM 1 ST OCTOBER TO 31 ST MARCH 2016 Allows for a comprehensive 12 month evaluation; Allows for a comprehensive 12 month evaluation; Allows for the introduction of the range of options necessary to maximise the services delivered within the CNU; Allows for the introduction of the range of options necessary to maximise the services delivered within the CNU; The 12 month evaluation presented to NHS RBCCG Governing Body in January The 12 month evaluation presented to NHS RBCCG Governing Body in January 2016.