Boundaryless patient flow across acute and community emergency care pathways

How Chelsea and Westminster Hospital NHS Foundation Trust is working with community services, GPs and industry to better manage emergency care pathways

Chelsea & Westminster Hospital NHS Foundation Trust (C&W), Central London Community Healthcare (CLCH), GE Healthcare Performance Solutions, and North West London clinical commissioning groups have jointly initiated a new Emergency Care Pathway Programme to improve patient flow between services.

Our partners built a model simulating the end-to-end patient pathway, which allowed us to understand the interconnected impact of change on the whole system

The objectives of the programme are to reduce emergency admissions by 5%, to deliver earlier supported discharge and rehabilitation, and to keep patients safely at home, at the same time as maintaining high-quality clinical outcomes and improving patient satisfaction with emergency care.

The first step was to set up a GP-led programme board, drawing together core members with key partners including the London Ambulance Service, social services, and clinical commissioning groups. The board then developed a boundaryless patient pathway model and each organisation consulted internally to identify key issues and potential solutions from the staff on the ground.

The operational transformation was scoped into four workstreams, each with specific goals, while ensuring an overarching view was taken by the programme board to build on the whole patient pathway thinking and ensure synergies between workstreams. The workstreams covered admission avoidance, streamlining acute flow, reducing length of stay, and community care planning.

A measure of success

At each stage of the pathway metrics were identified to measure and track success and to ensure quality and safety levels were maintained. KPI tracking was established and reported weekly to all stakeholders, along with an update on each workstream.

Cross-organisation working groups led each workstream, which enabled a wider perspective and new ideas to be generated. The approach was underpinned by data analysis and simulation modelling to broaden understanding of the challenge, informing decision-making and prioritisation.

“Our partners built a model simulating the end-to-end patient pathway, which allowed us to understand the interconnected impact of change on the whole system,” said a spokesman.

“A series of ‘what if’ scenarios then gave us a risk-free environment to stress test and evaluate potential changes.”

Among the scenarios tested were paid access ambulatory care clinics, virtual patient lists, nurse-delegated discharge, therapies collaboration, and step-up/step-down beds.

Analysis of the results showed that 1 in 3.5 admissions were discharged within 12 hours, suggesting patients were awaiting clinical assessment. Therefore, rapid-access acute medical and surgical clinics were developed within the C&W ambulatory care service. These offer an alternative to admission for ambulant patients requiring urgent consultant opinion. Historically, these patients would be admitted to AAU to be seen on the next acute consultant ward round.

This initiative has contributed significantly to delivering a 6.5% year-on-year reduction in emergency admissions at C&W during 2013/14. Patients are also being redirected from A&E to rapid access clinics, preventing hospital admissions.

We have set a precedent for collaboration between the organisations within this health economy which will be invaluable for ‘Whole Systems’ working and is already being replicated across North West London

A recent audit of the ambulatory service showed that only 8% of patients were subsequently admitted and 80% had their follow-up care managed at home. These clinics are consultant delivered and are available to A&E, GPs in the community, and to aid early supported discharge from AAU. The patient satisfaction survey for the Rapid Access clinics shows that 95% of patients would recommend this service, and also agreed that they were provided with all the support they needed. 80% agreed that ambulatory treatment allowed them to return sooner to their normal social activities, and 70% agreed they returned sooner to their daily routine.

Detailed analysis was also undertaken with CLCH around the key patient cohort of frequent attenders and/or admitters to C&W. Only 40% of this cohort were already known to CLCH, and, on average, from seven to 17 beds were consumed at C&W by such patients, equivalent of 502 bed days a month. This is a potential saving of up to £972,000 in costs within the acute setting.

Clinical review identified 11 priority areas for improvement to support these patients in the community, which are currently in delivery. For example, the community in-reach team is now identifying and assessing all frequent attenders in the hospital and referring them to appropriate services.

In parallel, work was undertaken to understand the implications for demand on CLCH services and the transformation required both in-service configuration and capacity, and also in communication and data flows to support pro-active care management.

Overall the programme has resulted in:

  • A reduction in emergency admissions of nearly 6.5% on last year’s volumes
  • Excess bed days reduced by 30%
  • Marginally reducing the readmission rate, while maintaining the A&E four-hour target at over 98%

Collaborative working

These changes have delivered a significant saving to commissioners and enabled the overall bed base at C&W to be reduced by 13 in Q3/Q4 2013/14.

There were also numerous additional benefits felt from whole pathway collaborative working between. The improved visibility of data through the dashboard reporting, data analysis and associated workflow technology is also enabling more pro-active management of patient care.

“Overall this programme has delivered immense value across all organisations involved,” said the spokesman.

“We have set a precedent for collaboration between the organisations within this health economy which will be invaluable for ‘Whole Systems’ working and is already being replicated across North West London.

“The programme has been supported by all parties to continue to a second year of operation, applying the lessons of year one and scaling up impact on the pre-A&E pathway and ambulatory care. A further focus will now be on reviewing and analysing delayed transfers of care to address these collaboratively with social care partners in the context of the Better Care Fund.

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