Community Matrons

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Community Matrons

• June 2007

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Community matrons the aim

• Improve health outcomes for people with long term
  conditions
• Offer a personalised care plan for vulnerable
  people most at risk
• Reduce emergency bed days by 5 by 2008 (2003/4
  baseline)
• Improving care in primary and community settings

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The current situation
People with long term conditions
Account for 80 GP consultations
50 of medicines prescribed for people with LTCs
are not taken
People with LTCs take up 10 of inpatients beds,
but account for 55 of in-patient days
A high proportion of these VHIUs are not on a DN
caseload
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Framework for managing long term conditions
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Referral Criteria

• Three or more active long term conditions
• Three or more AE attendances/ unplanned
  admissions
• Top 3 of GP users
• PARR score of gt50

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Case Management- what we do
planning
co-ordinating
Supporting people with long term conditions
managing
reviewing
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Benefits of Case Management

• Client-centred
• Improves clients functional abilities
• Effective use of resources
• Brings together primary and social care
• Prevents unnecessary admissions
• Reduces length of stay in hospital

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The Community Matrons role

• Comprehensive assessment
• Innovative case management
• Advanced clinical skills and medicine management
• Marshalling of resources and co-ordinating
  primary and social care
• Patients empowerment opportunities

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Key Challenges

• Developing a workforce
• Competencies, education and training
• Supervision and mentorship
• Data and information for case finding and risk
  management
• Systems change and integration with other services

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NHS modernisation and the Case Management
approach (1)
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NHS modernisation and the Case Management
approach (2)

• Intermediate care
• Connecting for health
• Single Assessment Process
• Extended and supplementary prescribing
• AHP role development
• New pharmacy contract

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Community Matrons
Through the unique combination of comprehensive
assessment, proactive clinical intervention,
marshalling of resources, assessment of the
quality of care and co-ordination of acute
primary and social care, enable people with
multiple conditions, affecting all areas of daily
living to remain in control of their own lives
CNO Bulletin, August 2004
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PARR Background

• The Kings fund was commissioned to develop a
  software tool for use by Primary Care Trusts to
  systematically identify patients who are at high
  risk in the future of readmission to hospital via
  emergency admissions.
• The PARR case finding algorithm tool became
  nationally available from September 2005.
• The software package was made freely available to
  NHS organisations on 1st February 2006. The
  current software package, PARR combines PARR 1
  and PARR 2

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PARR How does it work? (1)

• Clearly a large share of hospital admissions
  cannot be prevented or avoided. The PARR case
  finding algorithm does not identify patients
  randomly.
• PARR uses prior hospital discharge data to
  identify patients at high risk for
  re-hospitalisation in the 12 months following a
  reference hospitalisation.
• PARR aims to identify patients in real time who
  have a high probability of subsequent emergency
  admissions while they are hospitalised for
  certain reference conditions for which improved
  management may reduce the risk of re-
  hospitalisation.

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PARR How does it work? (2)

• PARR focuses on a range of reference conditions
  (including congestive heart failure, COPD,
  diabetes) where timely and effective case
  management can help reduce the risks of
  hospitalisation.
• An emergency hospital admission for a
  reference condition is a triggering event.
  This admission creates a risk score for the
  probability of another admission in the next 12
  months.
• PARR 1 and PARR 2 both use Hospital Episode
  Statistics (HES) data to produce a risk score
  showing a patients likelihood of admission within
  the next 12 months.
• Risk scores range from 0 100, with 100 being
  the highest risk.

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Identifying Patients with PARR

• We identify high risk patients, referred to as
  Very High Intensity Users (VHIU), and offer them
  care using a case management approach to provide
  proactive, co-ordinated and joined-up care in
  community settings.
• Evidence shows that intensive, on-going and
  personalised case management can improve the
  quality of life and outcomes for these patients,
  reducing emergency admissions and enabling
  patients who are admitted to return home more
  quickly (DOH 2007).
• Community matrons must be targeting resources to
  the VHIU in order to help reach the PSA target of
  improving care for patients with long term
  conditions, and reducing the use of emergency bed
  days by 5 by 2008 (DOH 2007).

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HIDAS

• Developed web base information system that acts
  as a reporting tool for the PCTs data warehouse
• Features include inpatient and outpatient
  activity, predictive tool, and long term
  conditions

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Outcomes

• Being a new service it is important that we
  monitor our outcomes to demonstrate our success
  and inform the development of the service
• We have carried out a six month audit from 1st
  October 2006 to 31st March 2007
• The information represents two caseloads with a
  total of 57 patients

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Age and sex of Patients

• We accept patients aged 18 and over, but the
  highest number of patients falls between the 75
  and 85 age group.

There are slightly more female patients, with a
ratio of 27 male 34 female
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Source of Referral
Most patients are proactively identified by
community matrons, with 30 (18) of patients
identified using PARR/ Hidas.
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Primary Diagnosis at Referral
We often manage patients with several co-existing
conditions, but referral is usually triggered by
a primary diagnosis
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Primary Need for Case Management
The community matron role can be divided into
four key interventions. This graph shows the
distribution of our key intervention.
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Prevention of Admission

• There is currently much debate about how to
  define or verify a prevention of admission, i.e.
  how does one prove that something has been
  prevented?
• We have compared admissions and GP usage before
  and during case management.

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Hospital admissions compared

• Comparing the figures before and after case
  management, a significant reduction in admissions
  can be seen
• From the 57 patients, there were 142 admissions
  recorded in total in the previous 12 months
• Since being case managed, patients have had 31
  admissions in 6 months
• Of those admissions, 28 were seen to be
  unavoidable or timely and 3 were preventable

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Number of Hospital Admissions
There is a significant reduction in admissions
for patients during case management compared with
prior to case management Over 90 of admissions
of patients who are being case managed are
unavoidable
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Reduction in GP home visits
Extrapolating figures from the audit to create a
full year effect, case management has reduced the
number of GP home visits by 162 visits a year
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Measuring potential admission avoidance

• Whilst we have gone to lengths to compare
  admissions before and during case management, we
  are also documenting occasions where we feel that
  an admission has been prevented
• We have divided these into acute episodes and
  extended episodes of care that potentially lead
  to admission avoidance

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Reduction to Service Usage following Acceptance
onto Caseload
Community matrons have orchestrated 39 acute
episodes where admission to hospital may have
been avoided. Extended episodes of care have
potentially prevented 76 admissions
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The future

• Community matrons around the country have sent
  feedback to the Department of Health asking for
  help in qualifying a prevention of admission
• A preliminary patient and carer satisfaction
  survey will be sent to all patients on the
  caseload this summer
• A more detailed 12 month audit will be carried
  out in November which will include cost saving
  information

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Case Study (1) Introduction

• 90 year old gentleman
• Medical History of COPD, AF, and Hypertension
• Discovered via PARR PARR score of 86
• Command of the English language poor
• Extremely hard of hearing
• Lives with his wife, his son, daughter-in-law,
  and their three young children in a three bedroom
  council house
• Daily care worker visit for washing and dressing
• Admissions to hospital in the year prior to Case
  Management 6 admissions equalling 39 bed days
  from April 2005 to April 2006

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Case Study (1) Assessment Outcome

• Poor understanding of and compliance with
  medication
• Inability to use inhalers and nebulisers properly
• Lack of follow up after hospital interventions
• Urinary incontinence
• Frequent exacerbations of COPD followed by
  hospitalisation

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Case Study (1) Intervention

• Referral to Audiology
• Use of an interpreter for teaching purposes
• Medicines management / Change of medication
• Education re use of inhalers, using volumatic,
  and nebulisers
• Organising a course of antibiotics and steroids
  on repeat prescription
• Education re signs and symptoms of exacerbation
• Family support

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Case Study (1) Outcome

• No admissions to hospital in the first 9 months
  of case management
• Improved communication
• Proper use of medication, inhalers and nebulisers
• Supply of pads for urinary incontinence
• Patient and family feel supported
• 2 hospital admissions and 10 bed days following
  case management

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Case Study (2) Introduction

• 80 year old man, lives alone
• Referred by Rapid Assessment Unit
• Fulfilled the criteria because
• Impairment in instrumental ADL
• 3 or more active LTC
• Top 3 of GP users
• High risk triggers falls and living alone
• COPD, IHD, Renal impairment, Chronic anaemia,
  Chronic gravitational oedema, L eye blindness,
  significant speech impairment, faecal
  incontinence.

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Case Study (2) Prior to case management

• In previous 12 months had
• 1 admisssion
• 1 AE attendance
• 2 ICT care episodes
• 13 GP home visits
• 6 GP surgery attendances
• Main focus of case management was improving
  social situation, care co-ordination, medicine
  management, monitoring health and acting as the
  patients advocate.

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Case Study (2) Assessment Outcome

• The patient was sleeping in a low cane chair and
  legs were extremely oedematous, affecting
  mobility, causing falls and skin breakdown
• Breathless and fatigued due to anaemia
• Faecal incontinence secondary to high faecal
  impaction
• Poor compliance / understanding of medications
• Poor social care due to reduced ability to
  express his needs and substandard carer input
• Social isolation.

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Case Study (2) Intervention

• Obtained new suitable chair from HES
• Referred to ICT OT for aids for bed
• Referred to DNs for skin care and compression
  hosiery
• Changed diuretics
• Requested carers ensure assistance to bed was
  provided in evenings
• Monitoring of Hb and referral back to RAU for
  blood transfusion
• Introduced medication policy for carers to assist
  with meds and inhalers
• Monitoring of bowels and laxative regime
• Wheelchair referral
• Referral to day centre, befrienders and good
  neighbours
• Ongoing monitoring of health bloods, BP, Pulse,
  temp, chest auscultation, weight, leg
  measurements.
• Ongoing social input order meals for weekends,
  liaise with good neighbours, feedback to care
  agency, act as advocate in complaints to care
  agency, follow up repairs and modifications to
  council

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Case Study (2) Outcomes

• No admissions or AE attendances in 7 months of
  case management
• 3 GP home visits, CM acts as first port of call
• Improved mobility, legs less oedematous
• Less patient frustration
• No further faecal incontinence or constipation
• Better compliance with medications
• Improving social situation and care input
• Example of where case management may have averted
  a future admission or crisis development of
  postural hypotension (increased risk of falls /
  injury) when dose of thiazide increased, so dose
  changed.

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Case Study (3) Introduction

• 72 year old man
• Lives with wife, who is main carer
• Referred by elderly care consultant
• Fulfilled the criteria because
• 3 or more LTC and 3 or more AE attendances
• Impairment in instrumental ADL
• High risk triggers include exacerbation of LTC
• PMH epilepsy, COPD, aortic stenosis, indwelling
  urethral catheter

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Case Study (3) Introduction contd

• 5 admissions
• 2 AE attendances
• 5 GP surgery attendances
• Under care of 5 consultants
• Presenting problems
• Catheter bypassing
• repeated UTIs
• bilateral lower leg pain and oedema,
• fluid overload
• medicine management.

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Case Study (3) Assessment Outcome

• Patient and carer had poor understanding about
  his various medical conditions
• Community nurses visiting to re-site catheter
  (approx every 2-3 weeks), and catheter bypassing
  most of the time
• Lower leg pain and oedema, not responding to
  analgesia
• Attending many different OPA

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Case Study (3) Intervention

• Liaised with urology consultant and requested
  review of situation and consideration of a
  supra-pubic catheter. Also requested review of
  medication
• Wrote to consultants explaining rationalising of
  care and now under the care of Elderly Care
  Consultant and CM
• Medication review
• Educated patient and carer about pts medical
  conditions and put individual care plans in
  place. Pt weighs himself daily and reports to CM
  if increase/decrease in weight. Pt and carer will
  observe urine output and contact CM if infection
  suspected. Pt reports any signs/symptoms of
  epilepsy promptly
• CM is first point of contact and then will liaise
  with appropriate member of the MDT.
• CM organised a Doppler and prescribed compression
  hosiery.
• CM liaised with elderly care consultant and
  arranged for the RAU to administer IV diuretic
  when weight, leg oedema and abdo distension
  became a problem

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Case Study (3) Outcomes

• 1 emergency admission (appropriate, but
  avoidable)
• No GP surgery attendances or home visits.
• 1 ECP visit (no action taken)
• 1 episode with ICT
• Experiences nil bypassing with supra-pubic
  catheter and DN changes every 12 weeks.
• Under the care of 3 consultants.
• Regular and planned visits by CM to monitor vital
  signs, monitor weight, measure abdo, assess pain,
  monitor epilepsy and offer carer support.

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Conclusion
The case management approach to LTCs has the
potential to have a great impact on the patient
experience and the effective and efficient use of
resources