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Identifying and Supporting Patient Groups with high Unscheduled Care (USC) Use

This step requires health and social care partners to agree a co-ordinated model to identify and support those groups of patients with high USC use, or who have the potential to be high USC users. The intended outcome here is the reduction of USC attendances, admissions and re-admissions for this group of patients.

Patients with Repeated, Frequent USC Encounters

It is well recognised that there are a relatively small number of patients who are unfortunate enough to have very frequent USC encounters that often result in Welsh Ambulance Service Trust/ Out of Hours/ Emergency Department attendance and/ or admission. These patients include various sub-groups including:
  • Predictably frequent service users (due to very complex medical conditions)
  • Chronic Disease Management care package failures
  • Social care issues/ complex mixed care
  • Frequent access in those without a formal mental or physical health problem

Multi-disciplinary/ agency teams can develop care plans and ensure that these plans are available and actioned during USC encounters.

Local measures can ensure that unnecessary USC consultations are progressively reduced, that longer term care management happens and that the patient does not unnecessarily re-enter the USC system at a different point of access. 


Intermediate Care Services/Community Response Teams (CRTs)

In order to support re-balancing of the system it is vital that existing, and developing, Intermediate Care Services target those patients most likely to default into a care sector that does not match their needs. This means that services will need to:
  • Share USC outcome measures as indicated previously
  • Target Ambulatory Care Sensitive Conditions, including re-admissions
  • Ensure the “pull” of patients from Acute Hospital Services to community services.
  • Provide appropriate support and governance systems for staff working in a setting that is not familiar to them 
    (e.g. clinical teams who have traditionally worked in hospitals but are increasingly working in the community)

Health Boards should be familiar with, and apply, the existing evidence base. The King’s Fund’s report Avoiding Hospital Admissions’ warns of the risks of ill defined case management resulting in unmanageable case loads, community virtual bed delayed transfers of care and unhelpful overlaps with core General Medical Services (GMS).

Key messages of the Nuffield Trust’s 'An evaluation of the impact of community-based interventions on hospital us’ include;

  • An integrated health & social care team focussing on patients with more than one long term condition is the model most likely to succeed. 
    The wrong model can increase hospital usage.
  • The success of implementation should be measured in real time so that ongoing failure can be avoided (by altering the model)
  • Monitoring success by measuring admission rates for the cohort of patients cared for will give a false reassurance of success as these patients' admission rates will drop off anyway. The patients' involved in the initiative need to be matched with a control group and a comparison made between the two. Monitoring success by comparing one locality with the Community Response Team in place, with another, without the Community Response Team in place) will not work: individual patients need to be compared with a control group of patients.
  • The right client group must be identified, the highest priority being those who have had a recent hospital admission

‘Near miss’ patients (those who could easily have been admitted but are successfully maintained in the community) are also high risk for future admission and should be actively managed. Whatever approach is taken by individual LHBs the most current evidence base should be followed and services actively monitored for success or failure (using measures integral to those relating to USC).