The challenge

 

The Whittington Hospital in North London is part of Whittington Health which provides general hospital and community services to 500,000 people living in Islington and Haringey as well as other London boroughs including Barnet, Enfield and Camden. As both a teaching District General Hospital and community provider, it is known as an “integrated care organisation.” It has more than 4,000 staff delivering care across the Whittington Hospital and from 30 locations in Islington and Haringey.

 

As part of the Emergency and Urgent Care division, the Ambulatory Emergency Care (AEC) Unit provides rapid access to diagnostic tests, hospital consultants and specialist staff in one place. It is a way of providing safe care designed around the needs of the patients. The aim is to avoid unnecessary hospital admissions. One part of this offer is the Virtual Ward (VW) which provides a service for housebound patients. It runs from 8am – 8pm 7/7 and has a skill mixed team including senior practitioners who are qualified in advanced physical assessment and non-medical prescribing.  They can take patients from A&E to prevent admission and from the wards to reduce length of stay. Patient’s care is transferred to the AEC Consultant, who is updated at least daily about the patient’s condition. As a hospital service, they are not borough specific and see patients from across North Central London. The service has been rated as CQC “outstanding” and now has a GP as part of the team 4 days a week, for Islington patients only. The VW service has recently expanded to take over the operation of the University College London “Hospital at Home” service.

 

The VW team provide over 2500 patient contacts a year, and in the last 12 months has worked with nearly 900 individual patients. As expected, this is an older patient cohort, with an average age of 77 years, and with 62% of the patients seen over the age of 80 years. The majority of patients have a short length of stay with the service (average 3.37 days) and can be visited by different members of the professional team.

 

Frailty is an important clinical problem that has been attracting increased interest across the health service. Despite differences of opinion regarding definition, it is accepted as a loss of resilience that means people living with frailty do not bounce back quickly after a physical or mental illness, an accident or other stressful event. In clinical terms, frailty is characterised by loss of biological reserves across multiple organ systems and increasing vulnerability to physiological decompensation after a stressor event. There are various frailty screening tools available, including electronic Frailty Index (used in primary care), PRISMA-7 (used by local Islington Community Ageing Team) and Clinical Frailty Scale (often known as Rockwood Score.)

 

Through data collected as part of the Winter Pressures scheme, we know that 90% of the Whittington VW patient cohort had a PRISMA-7 score of 3 or more; and 80% of patients had a Rockwood Clinical Frailty Score of 5 or more, suggesting high levels of frailty in this population. We also know that this is a higher burden of frailty than is seen in all attenders in the ED, and have demonstrated that there is limited correlation between age and Rockwood score.

 

Given the best practice standards of the British Geriatrics Society “Fit for Frailty” and Silver Book, patients living with frailty who have an acute health problem should be offered a Comprehensive Geriatric Assessment (CGA) approach to their care. Much of the evidence comes from hospital settings, but there is evidence that a CGA approach to frail older people in community settings could reduce hospital and nursing home admissions and increase the chance of continuing to live at home.

 

With the introduction of a frailty pathway in ED at Whittington, including the appointment of a specialist nurse for Older People (Frailty nurse), this is starting to become a reality.  However, there is an opportunity here to use the VW service to extend this offer outside of the hospital walls.

 

Part of a comprehensive frailty strategy should be to link hospital and primary care. There are existing frailty services in the community, although these are differently distributed across the boroughs covered by the Whittington. Patients expect their care to be provided by teams of well-integrated health professionals but research shows that many patients experience fragmentation, poor coordination, lack of information and confusion. A multitude of terms including integration of care, care coordination, continuity of care, collaborative care and joined-up care have been used, often interchangeably, to describe this important patient experience measure.

 

OUR PROPOSAL

 

We plan to use the existing service structure of the VW to provide an enhanced service for all patients living with frailty who are discharged from the Whittington ED. By offering a universal offer to all boroughs we will ensure equity and reduce variation in care experienced by our patients. We plan to use validated patient experience measurement tools (IntegRATE and CollaboRATE) to ensure the highest quality of collaboration of professionals and patients. The advantage of using measures that can be tracked in real time is the ability to apply Quality Improvement science, including PDSA techniques.  

 

We plan to track the safety of the service by continuing to monitor patients under the service who are readmitted to hospital. We know the current readmission rate is 1% directly from the service, and overall ED reattendance within 7 days of using the service is 2% (compared to 5% for all ages, 17% for over-75yrs attending ED, and 11% of those with a short admission <24hrs).

 

Qualitative work carried out in conjunction with our local Public Health team identified that this cohort of patients use different language to describe themselves, but all can describe changed life circumstances or difficulties in managing day to day activities. Additional insights were that this cohort often has low motivation levels and a reliance on carer support.

 

The extended VW work including CGA techniques would consider this. Specifically we wish to provide motivational interviewing training to our clinicians and build in closer ties to the voluntary sector offering carer support.

The money requested for this project will fund clinical service redesign (including service user engagement), education and training for multiskilled clinical practitioners in the VW team, and development of community links.  An additional anticipated cost will be for the inclusion of the patient experience tools into the clinical record system.