Our collaboration is delivering better care for older people

In designing new systems of care which are better suited to the needs of elderly patients living with multiple conditions and comorbidities, healthcare professionals have to provide more personalised treatment, and with fewer resources, than traditional models might allow.

‘We have the potential to lower the number of elderly patients who even need to set foot in a hospital’

One of the ways to meet this challenge of providing better care while also saving money, is to address not only what happens when older patients arrive through the hospital doors, but what happens before they even get there.

Over the last two years, I have been involved in a new pilot scheme called the Acute Geriatric Intervention Service. This is a collaborative initiative between Cambridgeshire Community Services and East of England Ambulance Service trusts: a multidisciplinary team of ambulance clinicians, physiotherapists, occupational therapists and a consultant geriatrician.

Lead therapists Annami Palmer and Philip Lumbard, an emergency care practitioner, were the two senior clinicians who were key in the development of the service, which bases its approach on the best practice guidance in Quality Care for Older People with Urgent and Emergency Care Needs (also known as The Silver Book).

The service responds to 999 calls and referrals from GPs: when a call comes through, the patient is attended by not only the usual paramedic crew, but also a therapist (either an occupational therapist or physiotherapist). They initiate a comprehensive geriatric assessment that is holistic and patient centred, taking in the patient’s physical health, functional ability, cognitive function, nutritional status, mobility and falls, as well as an environmental assessment. The service operates from 6.30am to 6.30pm, Monday through Saturday.

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No default option

A broad range of interventions can be considered at the time of contact: AGIS can provide functional equipment and walking aids, wound care and provision of some medications. It also makes appropriate onwards referral to a consultant community geriatrician, specialist nursing, community matrons, respite care, or ongoing rehabilitation such as balance and strength classes or community therapy.

‘Integrating the work of paramedics and therapists offers us a powerful and flexible set of skills’

As a result, we have the potential to lower the number of elderly patients who even need to set foot in a hospital, at the same time as providing them with more appropriate and personalised care. If admission to A&E is the right choice, then AGIS is of course able to provide this, but it’s no longer the default option.

In my role as consultant geriatrician, I review patient care during a weekly “virtual ward round” and provide telephone advice on specific cases. It’s clear to me that integrating the work of paramedics and therapists offers us a powerful and flexible set of skills in dealing with these cases.

Ambulance clinicians work autonomously within their scope of practice: they are skilled at “see and treat” and dealing with patients and relatives in their own home during a crisis. Therapists bring experience of working with the elderly in their home environments, and of providing workable solutions to problems around daily activities and mobility (a significant proportion of emergency calls received by AGIS relate to falls).

Difficult to measure

Therapists also actively promote independence and prevention activities, and have wide knowledge and experience of the available community referral pathways. Therapy interventions can happen at the point of crisis, rather than later, so there can be immediate improvements to the home environment and a physiotherapy assessment.

‘Additional time with a patient on first contact can save time and money down the round’

This is particularly beneficial for someone with dementia or cognitive impairment: it avoids the scenario of someone arriving a week or two later to ask about the patient’s recent fall, trying to tease out the underlying reasons, when the person may not even recall the event.

Saving money by avoiding unnecessary admission to hospital has also been a key driver for this service, as it is for many. However this is notoriously difficult to measure. A Nuffield Trust report highlighted the difficulties of evaluating integrated and community based interventions:

“The investment in a new pilot service brings with it an expectation on the part of the sponsors of the pilot that change will be detectable in a short period… there is typically significant pressure to show a positive evaluation result in terms of activity and costs in an unreasonably short time period.”

Despite this, AGIS has shown very encouraging results: in 2013-14 we “avoided” an average of 23 admissions per month, around 30 per cent (95 per cent confidence interval 26-35) of our total caseload. A visit is classed as “admission avoidance” through review of the notes at the virtual ward round, and consideration of what would have happened under a “usual care” scenario (eg: if only an ambulance had attended). While this measure of admission avoidance is in no way robust or definitive, it is transparent and serves as an estimate of potential benefit of the service.

We also saw 32 per cent (95 per cent confidence interval 28-37) of cases admitted to hospital appropriately with the added benefit of home assessment by therapists, which means that additional key information about the patient goes with them into hospital. Therapists can also ensure equipment is put in place and give useful information to hospital staff to aid recovery and timely discharge.

Time well spent

So what can we take away from all this? First, it’s worth issuing a slight caveat. There are many factors involved in success, and this model will not be a panacea for everyone; different structures, contexts, constraints and resources will all affect the provision of integrated urgent care in different areas.

Second, that allowing time for the service to develop and bed down was key, alongside collaborative working with commissioners. It took time to build trust and support from other professional groups and organisations to believe the service offered a safe and better alternative to usual care: all too often, the rush for quick-fix solutions can obscure our view of the bigger picture.

Finally, additional time with a patient on first contact can save time and money down the round: we have a target of 90 minutes to assess and treat each patient, but are able to go beyond this where there’s justification for doing so. Spending 2-3 hours with a patient may seem substantial, but if it allows them to stay at home safely and with equipment and services in place to prevent future urgent care crises, then it’s time well spent.

Dr Viveca Kirthisingha is a consultant community geriatrician at Cambridge Community Services Trust