Admission avoidance pilot gets off the ground

A city charity is working with GP Practices and Community Nursing teams, on a ground-breaking new project helping to prevent unnecessary hospital admissions in Sheffield.

Age UK Sheffield is working with 21 surgeries and community nurses within the city to complete “OK to stay” plans which give medical professionals important information about a patient. The plans may help people to  stay at home instead of being taken needlessly to hospital in some circumstances.

The charity’s Independent Living Co-ordinator, Joanne Appleby, explained: “One of the patients I worked with had previously been taken to hospital by ambulance crews on a Thursday afternoon because they were concerned there was little food in the house and she is diabetic. In fact, her daughter brings her shopping every Thursday evening so her food was due to be delivered in the next couple of hours.”

The plans provide medical information and additional critical information about how a patient manages at home with their mobility, medication, continence and nutrition. They also detail any communication difficulties, what their coping strategies are to deal with their health conditions and any special measures that can be put in place to enable a patient to remain at home. This can aid decision-making by ambulance crews and other health professionals.

Joanne added: “It’s not to stop people being admitted if they medically need to be. But if someone is breathless or has dementia they cannot always articulate how they normally live. Ambulance crews only get a snapshot, whereas I spend up to two hours with the person so I can gather information about their normal lifestyle. I supported a lady who has had low blood pressure for many years. Paramedics have previously seen that as a sign that she was becoming unwell and needed to go to hospital, but it was her normal state.”

The plans also record whether family members live locally and may be able to sit with the person, as well as having space to suggest things that are important to the patient if they need to go to hospital, such as if they have a hospital bag, and where their glasses and medication are kept.

The OK to stay plan was developed by a steering group involving many professions, organisations and patient representatives, grown from an idea of community nursing manager Rebekah Matthews from Sheffield Teaching Hospitals. After an initial pilot and positive evaluation the OK to Stay plan is now being used across Sheffield. Dovercourt Surgery, on Skye Edge Avenue, has successfully piloted the Age UK Independent Living Co-ordinator being involved in completing the OK to Stay plans and this model is now being rolled out to other local surgeries. Patients are referred to Age UK Sheffield after being risk-assessed by medical professionals as to their likelihood of hospital admission.

The charity provides the plans as part of their Independent Living Co-ordination service, which includes a benefits check to maximise people’s income, an assessment of additional support needed at home, as well as access to local resources, activities and transport.

Joint working with GP Practices, Sheffield Teaching Hospitals Community Teams  and Age UK Sheffield has considerably enhanced patient care by addressing the needs of the whole person, respecting their wishes and enabling them to have more control over their lives. In addition it has led to a much closer working relationship which has massive benefits for patients and health workers.  It has demonstrated how working across organisations is so much more effective than working in isolation. 

The collaborative work on OK to stay plans in Sheffield was recently shortlisted for the 2017 Health Service Journal’s Patient Safety Awards.