Practice example: Clinical Assessment Service (CAS) for care homes.

Who?

Lincolnshire Sustainability and Transformation Partnership

Lincolnshire Community Health Services NHS Trust (LCHS)

Lincolnshire Care Association (LinCA)

What

A local out-of-hours alternative to NHS 111 that provides nursing and residential care homes with direct and priority access to a dedicated clinical assessment service. The service is for urgent but not life-threatening cases.

Why?

The aim of the scheme is to reduce:

avoidable and unnecessary ambulatory conveyances to hospital
preventable hospital admissions.

Lincolnshire was using NHS 111 for

out-of-hours calls, but 111 is risk-averse and too many care home residents were being taken to A&E when it wasn’t necessarily the best option for them. The standard of clinical assessment could also be quite variable. This led to pressure on services in Lincolnshire and unnecessary stress for those residents who were taken to hospital by ambulance in the middle of the night when they could have been treated in their own beds.

Developed by LCHS, CAS for care homes offers the knowledge and experience of advanced practitioners and doctors with knowledge of local health and social care services. This approach means that people are much more likely to stay at home rather than attend A&E or if they need to go to hospital they can be directly admitted to a ward.

When?

The service was set up in December 2017 with the help of LinCA. The original intention was to focus on nursing homes. It was extended to care homes in early 2018.

How?

Key features of the scheme are:

Care homes have a dedicated number to call.
Callers do not have to go through a computerised decision-making process.

Clinicians are alerted as soon as a call comes through from a care home and callback is within 30 minutes. If the resident’s condition worsens during the callback wait, staff can dial 999.
Home visits can be arranged within two hours.
Medication can be prescribed.
There is direct access to hospital wards – A&E can be avoided if an admission is necessary.
GP records can be updated.

Challenges

The main challenge faced when the initiative was developed was about the need to assure stakeholders that the new system would not increase the risk to patients.

There was also concern because it

was difficult to estimate the volume and complexity of calls, and hence the level of resources that the CAS would need to provide.

Impact

Seventy-eight per cent of CAS calls requiring a home visit resulted in the resident being treated at home with no other services being involved.

Seven per cent were treated at home and referred to other services for follow-up, i.e. community teams:
- of these, 32% would have resulted in an ambulance/emergency department (ED) disposition had the care home contacted NHS 111 first
- only 12% resulted in an ambulance/ED disposition – 20% less than going through NHS 111. If these 20% had been conveyed, the cost would have been £161k. If all had been admitted, the cost would have been £2.3m.
Feedback from care homes has been very positive. They report increased staff retention and better morale because staff know they can reach out for an expert whenever they need one.

Case study

Mr P is 83 years old and lives in a nursing home in Lincolnshire. He has schizophrenia and dementia and also has poor general health. One Saturday morning Mr P woke up with a very red eye which was producing a yellow discharge.

The nurse on duty was concerned and didn’t feel that she could make the decision about treatment herself, particularly as antibiotics might be necessary. She called the CAS using the dedicated phone number and a GP called her back less than 10 minutes later. After listening to a description of Mr P’s symptoms, the GP said that the nurse should bathe the eye with a salt water solution over the weekend and observe it regularly. He said that she should call back at any time if she had any further concerns. Mr P’s eye problem soon began to clear up and he didn’t need any more medical attention.

Clinical Assessment Service (CAS) for care homes

Scheme