Will Emergency Response Service Bring Hospital Care To Older People?
A pioneering grassroots emergency service targeting frail older people who have fallen takes the hospital to the home in a money-saving solution that could help slash A&E admissions and offer a new model of community care.
“It’s almost like bringing to the home, services that patients would typically get in hospital,” explains Lea Agambar, a nurse practitioner for the new project in east London.
The service, a joint project between the London Ambulance Service(LAS) and North East London NHS foundation trust (NELFT), goes out to nearly 30 people each week and keeps most of them – an average of 77% – out of emergency departments. And according to NELFT, in the 12 months following its launch in October 2014 the scheme saved the health service £188,000.
After starting as a pilot scheme, it is now an ongoing service funded by Barking and Dagenham, Havering and Redbridge clinical commissioning group which, like other commissioners, is under pressure to cut A&E admissions. The target was set at a 15% reduction by the coalition government.
This is not one of NHS England’s vanguard models, but a relatively small-scale grassroots project conceived by staff from the two organisations.
“Our local emergency department was known to have some challenges and we were looking at the patients who come to A&E, what they present with, how they are conveyed and whether their admission was avoidable,” says NELFT service manager Caroline O’Haire.
“We’d already started some work with the LAS through our community treatment team, which works with people who are experiencing a health crisis in their own homes. So this was a further step.”
Agambar talks about how the idea emerged from a “frailty academy”, a forum for representatives from a range of services to meet and discuss the challenges that they and patients face, as well as possible solutions.
“We were asked to come up with an idea to help improve services for frail and elderly people within our boroughs,” she says. “So that’s when we decided about the emergency response scheme.”
The service uses a standard LAS emergency response car. But what’s different is, first, that it is equipped with devices for elderly people, such as walking aids and commodes. And, second, a paramedic is paired with a community nurse experienced in wound closure, urinalysis, blood sampling and more, and who attend to and assess the patients. People who have fallen receive a full falls assessment.
“We had basic and advanced life-support training, training from a geriatrician around falls and in physiotherapy and occupational therapy, as well as moving and handling techniques,” says Agambar.
At the outset of the service, the age criteria was 75 years and older, but that was reduced to 70 and now it is available for people aged upwards of 60. The patient profile has changed in other ways, too, as nurse practitioner Joanne Webb explains: “Initially it was for elderly fallers, but it was opened up to other elderly people who we can try and keep at home. So now we go to people who may have a chest or urinary infection, for example.”
Debbie Richmond, group station manager at the LAS, says staff working on the local dispatch desk in the emergency operations centre have been briefed about the type of people the car should, and should not, be dispatched to
“For example, if you’re going out to an older faller, there is realistically no reason to send this car if a patient is complaining of hip pain, because that patient will need to go to an emergency department for an x-ray,” she explains
“Also the dispatch staff have a contact number for the car, so if they’re not sure, they can contact the clinicians and decide what’s appropriate. The car has access to incoming calls via a computer. So the paramedic and the nurse can scan the calls themselves and if they feel a call is appropriate for them, they can self-dispatch.”
The King’s Fund has reported that people aged over 65 account for nearly 70% of emergency bed days in England (pdf) and, as O’Haire says: “The type of patients we are dealing with here are usually frail and have potentially a level of cognitive impairment.
“What we know is that when those patients hit an A&E department they become more confused, their presentation will worsen very quickly. If they get to A&E it’s highly likely they’ll be there for a very long time.
“Something as simple as going around, picking someone up, making sure they’re safe, will make them recover much quicker.”
So is it feasible for this service to be replicated? Carol White, a deputy director for integrated care at NELFT, says the service has been underpinned by a broader shift from a bed-based model to community care which has been taking place across the trust over the past three years.
She says: “I guess fundamental to this is a sea change in the whole system, and an understanding within this health economy that community health services had not been invested in sufficiently.”
She says the service could not operate without NELFT’s community treatment team, which provides follow-up care if that’s needed. And she believes it benefits from regular adjustments: “They are changing it all the time based on patient, carer or professional feedback, and I think that’s one of the keys to this success.”