A new unplanned admissions Enhanced Service (ES) has been introduced as part of a move to reduce unnecessary emergency admissions to secondary care. The new ES places emphasis on practice availability to patients at risk of hospital admission.
The main work of the ES is the proactive case management of at-risk patients (as with the former risk profiling ES), but will require coverage of 2% of the practice population over 18 years of age.
This enhanced service is funded through the releasing of 100 QOF points from the QP scheme and 42 million pounds funding from the 2013/14 risk profiling enhanced service (which has been discontinued), making a combined total of approximately 160 million pounds.
Establish the case management register
2. Inform patients
3. Put care plans in place
4. Offer a bypass number
5. Offer same day telephone access
6. Contact patient following discharge from hospital
7. Review care home emergency admissions and A&E attendances
8. Review register unplanned admissions, readmission and A&E attendaces
9. Complete quarterly reporting template for the area team
- Practices to use a risk stratification tool to aid in identifying vulnerable older people, high risk patients, patients needing end of life care and patients who are at risk of unplanned admission to hospital. A minimum of 2% of the practice's adult population (aged 18 and older), identified through risk stratification as being at the highest risk of admission, will be case managed proactively. In addition, any children with complex health and care needs requiring proactive case management should be considered. The resulting list of patients will be known as the case management register.
- Practices to provide vulnerable patients (identified through the above risk profiling) who have urgent queries with same-day telephone consultations or with follow-up arrangements where required.
- Practices to provide timely access via an ex-directory or bypass number to A and E clinicians, ambulance staff and care and nursing homes to support decisions relating to hospital admissions and transfer to hospital.
- Practices to produce personalised care plans for patients on the case management register (a national template will be published shortly). Care plans to identify a named accountable GP within the practice who has responsibility for the creation of each patient's personalised care plan. All care plans should be regularly reviewed as clinically necessary.
- Each care plan should also identify, if different to the named accountable GP, a care co-coordinator who would be the most appropriate person within the multi-disciplinary team to be the main point of contact for the patient or their carer to discuss or amend their plan. The care co-ordinator will also be responsible for ensuring that the agreed care plan is being delivered, that the patient or carer is informed of any changes made to the plan and keeping in contact with the patient or their carer at agreed intervals.
- Following discharge from hospital, practices to ensure that patients on the case management register or patients newly identified as vulnerable are contacted by an appropriate person (practice or community staff) in a timely manner to ensure coordination and delivery of care. Practices are also be required to review emergency admissions and A and E attendances of their patients from care and nursing homes. Guidance, to be published very soon, will address how practices with large numbers of care and nursing home patients will meet this requirement.
- Practices to share relevant information and any whole system commissioning action points with the CCG, and if appropriate the area team, to help inform commissioning decisions.
- Practices to undertake regular reviews of all unplanned admissions and readmissions for vulnerable patients (defined as patients on the case management register or patients newly identified as vulnerable) to identify factors which could have avoided the admission. Practices should also undertake monthly reviews of the case management register to consider what action can be taken to prevent unplanned admissions of patients on the register.
- The Enhanced Service will be monitored through practices completing a national reporting template, for submission to both the area team and CCG.