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HEALTH MPs, COMMISSIONERS AND TRUSTS SHOULD CONTACT TRIXIE BENNETT TO DISCUSS THE MODEL FURTHER

 

Summary

 

• Prevention of admission to hospital and facilitated discharge from acute hospital care is a key priority for the Lincolnshire health and social care system.
• The Prevention Admission Community Team was funded by Lincolnshire Partnership NHS Foundation Trust as capacity for the entire health and social care system.
• The aim was to prevent admission to acute care and support discharge.
• The service offer is to provide patients, who are referred by the hospital, with transport, support, companionship and help to “settle in at home” following discharge from accident and emergency or a hospital ward.
• Starting at Lincoln County Hospital in early 2013, the PACT team has achieved a significant impact on reducing admissions to acute hospital sites in Lincolnshire during 2013.
• The service is excellent quality and has received excellent feedback from people using it and from carers.
• During the twelve month period PACT received 2262 referrals, an average of 11 patients per day.
• The impact of PACT between February 2013 and 2014 was a saving of 1102 admissions.
• The cost of the PACT service per patient was £369.
• The cost of the PACT service per avoided admission was £757.
• The net cost saving to the system is estimated at £1.8 million based on a tariff price of £350 per night and working to assumptions agreed with the acute trust.
• A patient specific questionnaire has been in place for all people using the service from the commencement of PACT.
• Feedback indicates 82.6% of patients strongly agree that the PACT service improved the patient experience
• The majority of people who received the PACT service were older people, who returned to their own homes following discharge from accident and emergency or from the acute wards.
• There were a significant number of people who had been admitted to hospital following a fall in the community.
• The acute trust verified the data and has confirmed that the service played a contributing role to the management of the acute system during 2013 and winter 2013/14.
• The case studies included in this report demonstrate added value to the quality of people’s lives from the introduction of the PACT service.
• The recommendation is to continue to fund PACT in Lincolnshire as a first call on winter pressures funding and assess fully the overlap with the newly introduced well-being service.

Introduction

 

The Prevention of Admission Community Team (PACT) has been in operation at Lincoln County Hospital since February 2013.

It was commissioned by Lincolnshire Partnership NHS Foundation Trust (LPFT), initially from transformation monies, to fill a deficit in the system of care and to test a concept of: –

• Supporting the Lincolnshire health and social care system (acute, social care, community liaison services) to prevent people being admitted through accident and emergency, if the patient had a social need, all medical needs were met but where the person may have needed a period of “settling in” once they were home; and
• Supporting the acute discharge system by providing a support service to get people home, once they were medically fit for discharge.

The original aim was to support 10 people per day to get home from the hospital.  The PACT service is provided in a unique collaboration between Adults Supporting Adults, Age UK Lincoln, Lincolnshire Home Improvement Agency and LACE Housing Association.

The service commenced at Lincoln County in January 2013 and following support from commissioners and from the acute trust, was rolled out to Grantham Hospital and Boston Pilgrim Hospital in December 2013.

PACT model of service

 

The PACT teams are staffed by trained workers who have all of the required employment checks and work to the policies of Adults Supporting Adults, the lead agency for administration purposes.  The service is registered with the Care Quality Commission and thereby subject to regulation and standards for safe services including safeguarding adults.

PACT teams work into the three hospital sites in Lincolnshire, with the full co-operation of the discharge teams and accident and emergency teams and community services.

The PACT service is for all adults and both physical and mental health care, being offered as capacity to assist the system in delivering better flow of patients and in assisting the acute trust in its operation.

PACT receives referrals from the acute trust, working to an agreed protocol.  Once a patient is referred and accepted by PACT, the governance processes for PACT are initiated and the responsibility for all aspects of a person’s care and safety are transferred, including liability insurance.

PACT supports people with a social need and provides transportation to and from the patient’s home and helps them to settle in or readjust to independence following discharge from the acute hospital environment.  The transport home is provided by LACE Housing Association as part of the collaborative, in fit for purpose vehicles, including facilities for people using a wheelchair.  The partners in the collaborative (Adults Supporting Adults and Age UK Lincoln) are registered providers of personal care with the Care Quality Commission and are regulated for this activity.

People are accompanied by a driver and a worker on the journey home.  The worker then settles the person in to the home environment, ensuring that the person is safe, has a drink and food available, that the heating is on and general companionship and support.  Whilst the team is with the person, they take the opportunity to assess the home environment for any hazards including slips, trips and falls risks.  In the event of any concerns, the PACT worker remains with the person, whilst the driver returns to base.  All support and intervention is agreed with the client and the family or carer.

All workers are trained, wear a uniform and have identification badges at all times.  All staff have a full DRS check, complete recognised induction training and receive on-going training.  All patients are treated with courtesy and respect at all times.  A questionnaire is issued to each person as part of the evaluation of the service.  The PACT service has dedicated contact numbers at each hospital site and co-ordinators receive and accept referrals.  The co-ordinator has the right to refuse a referral if they believe that PACT cannot fulfil the person’s requirements.  Transport is provided within 2 hours following the request unless the person requests an alternative arrangement.

Number of clients supported and number of avoided admissions

 

The original aim of PACT was to support 10 people a day across Lincolnshire, with a view to either preventing an admission from accident and emergency departments to hospital, or supporting the discharge of patients’ home from hospital.

 

The premise was that that a person would be referred to PACT on a formal basis, usually from an acute trust clinician, working to an agreed protocol or flow chart.

 

Once accepted by PACT, the service then undertakes full responsibility for the care and well-being of the person, working to the policies and protocols of the PACT service.  These are regulated by the Care Quality Commission in line with key standards and/or the Charities Commission.

 

The figures show that on average, with the full roll out to Grantham and Boston, the PACT teams receive on average 11 referrals per day.

 

In total 2262 people were seen by the PACT teams during the 12 months to February 2014.

 

Of this number of people who were transported home and supported back into the home environment, 1102 (41%) avoided an admission to the acute hospital as a result of the intervention and support of the PACT team.

 

The conversion rate of hospital admission from accident and emergency increased over the period.

Data were collected for each person accessing PACT from the start of the service.

From analysis of the individual patient data returns, the number of people referred to PACT and the trend over time is shown in the table below: –

 

Summary All Sites
	Lincoln		Boston		Grantham		Total
Month 2013 to 2014	Number of referrals	Referrals per day	Number of referrals	Referrals per day	Number of referrals	Referrals per day	Number of referrals	Referrals per day
Feb	52	1.9					52	1.9
Mar	97	3.1					97	3.1
Apr	106	3.5					106	3.5
May	138	4.5					138	4.5
Jun	117	3.9					117	3.9
Jul	114	3.7					114	3.7
Aug	110	3.5					110	3.5
Sep	135	4.5					135	4.5
Oct	136	4.4					136	4.4
Nov	147	4.9					147	4.9
Dec	191	6.2	92	3.0	112	3.6	395	12.7
Jan	154	5.0	124	4.0	123	4.0	401	12.9
Feb	130	4.6	91	3.3	93	3.3	314	11.2
Total	1627	4.1	307	3.4	328	3.6	2262	11.2

 

The primary objective of the PACT service was to support the acute trust in Lincolnshire, and the rest of the health and social care system, to improve the quality of the patient experience and to alleviate pressure on the accident and emergency departments and acute hospital beds.

Analysis of the data also included the extent to which the PACT service, in receiving a patient, was then able to prevent an avoidable admission to an acute hospital bed at the United Lincolnshire Hospital sites.  This is a difficult concept to prove given there are so many factors that influence the treatment of patients.   However the figures in the table below indicate some interesting potential and an impact that is positive.   This potential deserves further time to realise the full impact of this type of new service in the system.  It has support from acute and community staff, medical staff, MPs and has received national attention.   The PACT service had a demonstrable impact on reducing admissions and lengths of stay.  The total number of avoided admissions is 41.4% of the total patients seen (all sites), indicating a saving to the acute system of 1102 admissions during the year.  For Lincoln, where the service has been established the longest, 47% (770) of patients seen avoided admission.   Lincoln Boston Grantham All sites Total Clients Avoided Admission Total Clients Avoided Admission Total Clients Avoided Admission Total Clients Avoided Admission Jan-13 9 9 9 9 Feb-13 52 44 52 44 Mar-13 97 73 97 73 Apr-13 106 69 106 69 May-13 128 66 128 66 Jun-13 117 58 117 58 Jul-13 114 56 114 56 Aug-13 110 38 110 38 Sep-13 135 33 135 33 Oct-13 136 43 136 43 Nov-13 147 78 147 78 Dec-13 192 87 85 51 111 71 396 209 Jan-14 154 63 124 63 123 60 401 186 Feb-14 130 53 91 43 93 44 314 140 Total 1627 770 300 157 327 175 2262 1102   The characteristics of patients where admissions were avoided through the support of PACT are: –   Patients who were medically fit to go home, but who needed additional social support; Patients who without the support of PACT to get them home, escorted, would have needed admission to a hospital bed; People who are older (average age of the PACT client was CCC years); Patients who are living in their own homes (90%+) or care homes (95%); People who were not in receipt of social care packages.   These data were tested with United Lincolnshire Hospitals NHS Trust as part of a data reconciliation exercise and the following feedback from the acute trust was confirmed: –   The health and social care system needs to develop a case for the PACT service to continue because the service has been well received in the pilot phase.  It does appear to be having some effect and is well regarded as a quality service. ULHT’s currency is bed days and from the data it is difficult to correlate the savings described with a ward closure of 28 beds.   The service enhances the quality of service provided and the discharge of a patient rather than the closure of a ward. Having reviewed the data, PACT was able to save one overnight stay per day on average for patients who attended A&E/Ambulatory Care.  The usual route for patients 75 years and over who come through this route is to spend one night in hospital whilst a care package is being set up for the next day.  The PACT service is able to take that patient home earlier. For patients being discharged, PACT was contacted on the day and took the patient home that day.  The usual process for booking transport is the day before, if this has not been done and the patient is discharged then could assume 1 day length of stay reduction. The average cost of one night in an acute bed is around £350. In winter 2012 ULHT had 107 escalation beds open and at the time of the data reconciliation (early February 2014) there were 6 escalation beds open at Lincoln County Hospital. ULHT provided the cost of a bed for both surgical and medical cases, rather than using the national figures.  This was £350 per night and is used in the forecasting shown below. ULHT was not an outlier nationally for re-admissions of patients.

Economic Impact

Analysis of the characteristics of the patients who were supported to avoid an admission along with the data verification exercise undertaken with the acute trust, indicate that the case mix of patients in terms of tariff were at the less complex end of the spectrum.  This in turn indicates the lower end of the cost saving spectrum for the economic analysis.  In agreement with the acute trust, a cost per bed night of £350 was used to calculate the cost saving of the avoided admissions.  This was agreed with ULHT following joint analysis of the data, end to end, and working to a set of assumptions about the likely onward route of the patient.  A gross bed night saving was calculated at £1.1 million, with a net saving of over a quarter of a million after offsetting the cost of the service.
	Lincoln	Boston	Grantham	Total
Total Number of Patients Supported	1627	307	328	2262
Estimated Total of Bed Nights Saved	2398	425	448	3271
Cost of Bed Nights Saved @ £350 per night (£)	839,300	148,750	156,800	1,144,850
PACT Cost incl. set up costs (£)	602,879	142,075	138,249	883,203
Saving (£)	236,421	6,675	18,551	261,647

 

When scaled up for all of the three sites the potential net saving to the system is £1.9 million as shown in the table below.

 

!2 month forecast for all three sites	Lincoln	Boston	Grantham	Total
Total referrals received	1910	1470	1370	4750
Minimum bed nights saved	3350	2526	2326	8202
Gross bed night saving at £350 per night£000	1172	884	814	2870
Cost of PACT£000	344	314	314	972
Total net saving				1898

 

Therefore the total estimated annually projected economic impact of PACT on reducing lengths of stay in Lincolnshire is £1.8 million net.

 

This figure is a significant under estimate of the potential impact of the service given: –

• The PACT service does not always receive sufficient referrals each day to optimise the use of available PACT capacity;
• There are delays to approximately 75% of the patients referred to PACT due to acute hospital internal processes, most frequently delays in the patient obtaining TTOs from the hospital pharmacy;
• The core hours of PACT were reduced at the end of February 2014 due to uncertainty around the availability of funding.

Patient stories

 

To PACT service ethos is to add to the quality of care provided as illustrated by the following case studies.  The common theme running through these studies is the value added by the personal service provided by the PACT service – giving a new dimension to integrated working: –

 

Lincoln

Case 1 – an elderly man originally admitted following a fall and had a history of falls in the last few months.  PACT team took him home and on arrival noticed the stair lift did not work.  PACT team settled patient in at home he was very worried and anxious because of stair lift, so the PACT team member contacted the son who gave phone number for stair lift company.  PACT phoned the company who assured the team they would get to the property within the hour to fix the lift.  Client was reassured by staff and was more relaxed when they left.  The PACT team co-ordinator rang the next day to ensure lift had been fixed – client advised the engineer had visited within an hour and fixed the lift, he was very grateful.

Case 2 – an elderly lady with a history of falls was in hospital after another fall.   The client also had diabetes and lived with her son who would not be at the property until the evening as he worked all day.  On arrival at the property the client’s son advised the phone line had been cut off.  The PACT team were concerned because the client would not have the added support of the Lifeline.  The PACT team member rang the team co-ordinator who contacted the community nurse who deemed that the client would be at risk without the Lifeline.  A respite bed was organised and the PACT team stayed with the client and then took her to the Care Home.

 

Case 3 – an elderly gentleman who had fallen who was escorted home by the PACT team who returned him home and settled him in, after having a conversation with him he gave permission for the team to refer him to Age UK for a benefits check.  A referral was made and the co-ordinator rang at a later date and he advised someone had been to visit him and was giving him a lot of support regarding this which was ongoing. This visit also resulted in another referral to have an assessment for equipment etc.  The gentleman commented that he was very pleased and felt his life was improving.

 

Case 4 – the Air Team referred an elderly gentleman who had had a fall at home, and was in A&E. The PACT service took him home and on arrival at the property discovered that his wife has Dementia and was quite confused.  The client was settled in and the team also made the client aware of trip hazards and removed some rugs at his instruction.  The PACT team member also rang the Care Agency to reinstate the care package.  Also, the client agreed to have a Lifeline installed which the PACT team did whilst there.  The client was very relieved to be home with his wife as he was worried that she would be taken into care if he couldn’t look after her.

 

Case 5 – a lady had been admitted to hospital due to accidental overdose of her medication and was referred to PACT for support on her return home due to her level of vulnerability.  It was also stated by the medical staff that she suffered depression.  After settling the client into her home she said she was very lonely and had previously tried to commit suicide, she had not been out of the house for over a year.  PACT team members stayed and talked to her and spoke about organisations that could help.  The client said she had contact with the Samaritans but agreed to a referral to the Age UK Befriending Service.  The team co-ordinator made a referral to the Befriending Service and a visit was made and service is ongoing.

 

Case 6 – an elderly lady was taken home from a ward, she had been waiting all day for medication and needed to be home in time for planned care call.  When on arrival at the property it became clear the care call had already been, the PACT team carried out Personal Care.  The client was taken to the toilet and supported to undress for bed at which point the PACT team came across a cannula left in situ.  The PACT team contacted the ward who advised to bring patient back or ring GP (client lived 20 miles away and this was late at night) because of the late hour the PACT team member rang the GP, was advised to ring 11 who advised a Doctor would be in touch within the hour.  The PACT team carried on with settling in the client, put her to bed, made her a cup of tea, ensured she had everything to hand and reassured her husband.  After half an hour the Doctor rang and said someone would be visiting to take out the cannula however by this time the daughter had arrived and advised she would wait for the Doctor.   Patient and family very pleased with PACT support.

 

Case 7 – a palliative care patient with breathing difficulties was referred to PACT by ward staff for support to enable her return home to be with her husband.   When the PACT team got her home she advised she needed to be washed, put on clean underwear and nightie, supervised her to clean her teeth, made her a cup of tea, brought in the bowl so she could soak her feet and settled her down for the day.  After this Client G said she felt human again.

Grantham

Case 1 – a patient was referred to PACT for assistance to return home following admission due to UTI and fall at home.  The patient lived alone and a care package was due to start the next day.  On arrival at home it was evident that patient was experiencing pain in knees when transferring so the PACT team helped him to get ready for bed, to use commode and ensured that necessary items were within reach.  Commode emptied and patient left comfortable.

 

Case 2 – a patient was referred to PACT from A&E as she had attended after falling at home, she had a chest infection and needed additional support to return home, was about to breach the 4 hour target but did not need to be admitted.  The PACT team took the patient home and helped to settle them in at same time identifying that Lifeline support could be beneficial.   A Lifeline was fitted by the PACT team and the patient was very satisfied with the support given.

 

Case 3 – a patient was referred to PACT after being in hospital for a month, he had COPD, CA lung, chest infection and depression.  PACT transported the patient home and on arrival discovered that the property had not been checked whilst patient in hospital.   With the permission of the patient PACT staff disposed of mouldy food, washed dirty dishes, emptied bucket of stale urine and generally tided and cleaned living area.  The next of kin was informed of the patient’s return home.  Patient was left with a cup of tea and in reasonable comfort.

 

 

Boston

Case 1 – a 97 year old referred from the ward to PACT for transfer to care home.  The alternative transport provider had agreed to transport the patient but had later advised they could not do so until after 22:00.  The patient had been admitted due to heart failure, shortness of breath, liver failure and pneumonia and was very keen to return to the care home which she described as her home and was very grateful that PACT had returned her by 20:00.

 

Case 2 – an 85 year old man was referred from A&E, had UTI and history of abdominal aneurism, bilateral tumours on kidney, multiple cysts and diverticulitis.  He walked with the aid of a stick and needed reassurance on the journey home.  His wife was waiting for him at home and medication needed to be collected en route as hospital pharmacy had closed at noon, this being a Saturday.  The patient and his wife were very pleased with the help from PACT.

 

These case studies indicate a positive impact on the outcomes for patients and illustrate the added value to the hospital system and to patients of providing a quality service, wrapped around the needs of the patient and carer.

At the outset of setting up the service, it was anticipated that the quality of service for patients could be improved by providing simple additional elements to supplement the hospital service once a person’s acute physical health needs had been met. 

The case studies presented above indicate the art of the possible where the system can work together to achieve improved quality without compromising the added value of the contribution of any partner in the health and social care system.

They also illustrate the unique contribution of the third sector to improving patient care when the statutory sector has completed its work.

Patient feedback

 

Analysis of the questionnaire results overall indicate the following key results: –

• 69.57% of patients strongly agree that the PACT service is delivered in an acceptable timeframe
• 78.26% strongly agree that the PACT service made a significant difference to the hospital stay
• 82.6% strongly agree that the PACT service improved the patient experience
• 90% of respondents state the PACT service reduced the length of stay by 2 days

And feedback from staff includes: –

“The PACT team are brilliant. They are always smiling and make patients feel at ease. They add a personal experience into patient transfers and they will go into the patient’s house to make sure they are settled and to see if the patient needs anything.  I have had a great experience of the PACT team and I highly praise them for the service they deliver and the timely manner with which they respond”.

 

The following section gives verbatim feedback from people who returned the PACT questionnaire: –

DECEMBER 2013 – BOSTON – 106 referrals and 52 responses (50% response rate)

1. Very pleased
2. Very good
3. Good service
4. 100% better than any other service we have had
5. All very good
6. Didn’t realise this morning I would meet such lovely people.  Couldn’t do enough for me
7. Very pleased with service, would use you again
8. Good service
9. Happy with service
10. Superb hope it keeps going
11. Appreciate what you’ve done
12. Excellent
13. Very happy
14. Good service
15. Excellent
16. I am so grateful so pleased to meet such lovely people
17. I can’t speak highly enough of you, I’m very happy with what you have done for me
18. Lovely people
19. Very friendly
20. I wouldn’t make any changes to the service it is very good, I will tell people you’re the tops
21. Good service
22. An excellent service provided by a very good team.  I would highly recommend this service, you all helped to boost my morale
23. The link between hospital and PACT was very professional
24. Everything perfect
25. Service could not be beaten
26. I wish I’d thought of you earlier
27. Nice journey home
28. Couldn’t have wished for two nicer ladies
29. All satisfactory
30. Keep up the good work
31. Brilliant

DECEMBER 2013 – LINCOLN –163 referrals and 62 responses (38% response rate)

1. Cannot be beaten
2. It’s a good service
3. Good all round service
4. Pretty good service, no complaints
5. Lovely service
6. Nice journey
7. Wonderful service, people make me feel at ease, I would recommend it
8. You’re lovely, helpful, couldn’t ask for nicer people
9. 100% efficiency
10. It’s been a fantastic service, my husband is disabled and would have found it difficult
11. Good idea and excellent service
12. It is brilliant
13. Very happy with PACT service
14. 99.9% perfect
15. The team give a very good service
16. An excellent service
17. It’s a very good service
18. Transport 100%, very good for the in getting me home
19. Well looked after thank you
20. Disappointed that I wasn’t allowed to give the girls £10
21. The best thing is that you are of an older age, people will trust you and feel safe
22. I couldn’t fault it, nice ladies and Nigel was marvellous
23. Thoroughly enjoyed the trip
24. Merry Christmas all been wonderful
25. Very good service
26. Very helpful and very kind
27. Works fairly well, driver very good
28. Very prompt and very efficient
29. Faultless service
30. Excellent service, came so quick
31. Excellent very grateful indeed
32. Very good service
33. Your service is excellent, looked after me well
34. Lovely ladies made the journey pleasant
35. Fantastic service
36. Excellent service

DECEMBER 2013 – GRANTHAM – 110 referrals and 82 responses (75% response rate)

1. Enjoyed ride and company
2. Excellent
3. Excellent service
4. Wish to say thank you
5. Everybody went to a lot of trouble to help me
6. Nothing to improve on
7. Very good service, very grateful for your help today
8. Do a good job
9. You have all been very kind
10. You need to have more lay flat transport, not everyone has ability to stand and travel in a chair
11. Did a wonderful job
12. Couldn’t fault PACT
13. Would like to thank the whole team including the driver
14. Very good service
15. Very good service
16. Thanks so much
17. Very grateful for your help
18. Thank you very much
19. All excellent
20. Customer said he was satisfied
21. No all ok
22. Extra ambulance would be helpful to speed things up
23. All satisfactory
24. Efficient, friendly, pleasant and great
25. Couldn’t fault it
26. A fine and very helpful staff – 1^st class
27. Very pleased with the service
28. Wonderful care – best ever – everything I wanted for my uncle (92 next month) I would love to have these people looking after me
29. Brilliant
30. Excellent
31. Everything ok
32. It was good to feel supported on the first evening home
33. The people were so helpful I am so happy to have such wonderful  help
34. Very good helpful
35. Excellent service
36. The staff were excellent cannot fault them at all
37. Very impressed and grateful
38. Top service from you
39. So glad that PACT team got me home so safe and quickly
40. Happy and satisfied

Conclusion

 

The analysis presented above indicates a significant potential improvement in the quality of patient care as well as reduced un-necessary admissions to hospital and cost savings of approximately £2 million per year.

Whilst this is a very difficult area to calculate, the impact of this service warrants further exploration and an extension to the funding to secure it for a further six months pending an academic evaluation.

Commissioner, community support and acute support is vital to this service in the future.

May 7th, 2014