Single point of access and rapid response- information for design

Why a single point of access? Currently at least 6 ways to access intermediate care…

What is a rapid or urgent response? Two parts: Rapid access to an integrated health & social care assessment in the home environment, directly from the community In-reach into A&E, MAU, acute wards and other bed based services to assess health and social care needs and facilitate discharge. Currently this type of rapid assessment only available once someone has accessed acute services e.g. RAPT, IDT, STEPS via SPOC. In the future needs to be accessible directly from the community to avoid A&E attendances and admissions. Key points from review; This response would assess and develop a care/ support plan to meet the immediate health and social care needs of a person and facilitate access to appropriate support/ services to deliver that plan. It would need to have rapid access to home based reablement support and/ or increased home-care. Single point for assessment and access to IC services (bed and home based) Could also include a crisis falls response.

Evidence Base for rapid response

National guidance NHS England suggest that frail, older people should have access to rapid support close to home in crisis. Their guidance, on developing pathways for frail older people, cites work by the Kings Fund (2013) and the silver book (2012) recommending 8 interventions that should be available as part of a rapid response; Single point of access. Comprehensive Geriatric Assessment Ambulatory emergency pathways with access to multi disciplinary teams within four hours. Mental health assessments as appropriate Access to a community Geriatrician for expert clinical opinion, clinical support and supervision. Rapid access to ambulatory clinics available in acute trusts and community settings. Personalised care plans including emergency contingency plan, advanced care plan and EOL plans. Shared care protocols with ambulance services to enable older people to stay at home. NHS England February 2014   Services that are able to respond quickly in a crisis play a major role in reducing admissions to secondary care and maintaining people at home. Admission avoidance is a key function of intermediate care services.  National Audit of IC 2015  

Who else is doing it? Birmingham Rapid Response Service http://www.bhamcommunity.nhs.uk/about-us/clinical-services/adults-and-community-services/rapid-response/ London Rapid Response Service  http://www.urgentcare.org.uk/rapid-response-urgent-care.html   Croydon Rapid Response Service    http://www.croydonhealthservices.nhs.uk/rapid-response- service.htm Rapid Assessment and Time Limited interventions Team (RATL) North Lincolnshire & Goole NHS Trust http://www.doncasterccg.nhs.uk/wp-content/uploads/2016/06/RATL-North-Lincs-Goole-Helen-Davies.pdf  iCares Sandwell   http://www.doncasterccg.nhs.uk/wp-content/uploads/2016/06/iCares-Sandwell-Sandra-Kenerley-and-Helen-Bessant.pdf

Who needed a rapid/ urgent response? Gender: Female 59% Male 40% Age- The majority of people who needed a rapid response were over 80 years old. 46% were between 80 and 90 and 22% were over 90.   Home situation- 59% lived alone. 22% lived independently and 36% with support from informal carers and family.

Who needed a rapid/ urgent response? Heart problems- were the most common conditions in the past medical histories for this response (10% more than those who required a bed based response). Dementia/ Cognitive Impairment- 18% of people had an existing diagnosis of Dementia and another 6% had a history of cognitive impairment. On assessment these people had medium to high levels of need around memory and cognition. End of Life- 7% of people who needed a rapid response required it to facilitate prompt access to end of life care. 17% had currently or previously had a diagnosis of cancer. 22% had pain that was not resolved by simple analgesia. This is also the only response where people had very high needs around pain relief (2%). This could be connected to the end of life referrals. Local Infection- 10% had a UTI, chest infection or other local infection. Wounds- A quarter had a wound or needed some sort of dressing. The majority only needed a simple dressing, but 4% needed something more complex.

Who needed a rapid/ urgent response? Reduced mobility- prior to this episode 23% were independently mobile and 54% used a walking aid. On referral to intermediate care, just under half needed supervision (40%) or physical assistance (9%) to walk. 6% were unable to mobilise at all. Falls-41% had fallen but only one quarter had sustained a fracture and these were generally not fractured neck of femurs or fractures requiring unplanned surgery . Social reasons led to 5% of the referrals for this group and concerns about social situation or potential safeguarding/ risk issues were identified for 6%. Carers 3% needed a rapid response due to carer breakdown. 12% of the carers identified in this response needed formal carer support, could not continue to care or required a care package themselves. Home environment- Over 13% required a home assessment or provision of equipment/ minor adaptations Over half needed support with domestic activities (including meal prep) at the point of referral and 15% were fully dependent. Just over half also needed some support with personal care. Another 21% needed significant support with personal care.

What types of interventions were needed?

What types of interventions were needed? Medical investigations included… X-rays Blood tests/ urine screen ECG DVT investigation Clinical interventions identified were… Catheterisation Antibiotic treatment (oral) IV antibiotics. Pain relief Dressings

What types of interventions were needed? Other types of interventions… Access to emergency basic household equipment/ furntiure. Facilitate downstairs living. Advice/ education for informal carer. Liaison with partner’s care team. Best Interests meeting. Care planning Continence assessments Joint discharge planning with hospital/ bed based service. Mental health assessment/ Dementia review Safe guarding assessment Signposting/ refer to wellbeing Refer to telecare

Who is needed to deliver them? Most frequently identified Occasionally identified Home environment ssessment OTs Therapists Community IC service Reablement Case manager/ worker Medical/ Clinical Review Clinically trained falls assessor (ECP/ GP/ANP) GPs ECPs Geriatician/ Frailty focussed practitioner Settling in visit (home from hospital) CVS Reablement workers Existing care provider MH worker, Dementia Navigator etc Mobility/ transfer assessment Physiotherapy Manual Handling assessor Functional/ ADL assessment Reablement Mental health trained Social Care assessment/ review existing home care package Social Care Worker Social Worker XXX Provision of equipment Physiotherapists Reablement case managers Any of community IC team In-reach by community intermediate care team to facilitate discharge (home from hospital) Community Intermediate care service Carers assessment Social Care Staff Mental health workers Access to EOL care Appropriate to individual MDT Nurses Palliative Care Team Medication review/ advice Falls Assessor/ ECP GP Pharmacy MH workers/ Psychiatrist Clinical Intervention ECP/ Falls Assessor (see above) Nurse Access to respite Social Care staff Medical Investigations/ tests Falls Assessor/ ECP/ ANP Phlebotomy RAPT type assessment Community based team Team in A&E Capacity assessment Mental Health Social Care

What patients told us…

What GPs told us… Single point of contact with one number- which can then sign post to all services Single assessment process Health social care team- joint Same day assessment or led by need Anyone can refer to service Period of open access to IC service post discharge Need for care coordination  and care planning Need family to recognise their responsibility to make referrals IC service needs to include MDT approach – use of voluntary sector & pharmacists Need an integrated IT system- GPs only want update /request for them to do something Skilled workforce to up-skill care home and carers to avoid unnecessary admissions Rapid assessment to be completed by skilled clinician – ANP/ECP