Care Coordination shows early promise

Devon’s health providers are working together to help keep ambulance crews on the road, with a new proactive approach to connecting suitable patients to an urgent community response.

The Care Coordination model sees the ambulance service stream suitable 999 calls to expert clinicians who can advise, prescribe and refer to appropriate primary and community pathways. It creates a single route to access the support of the community, showing early promise in Plymouth and West Devon.

What is the Care Coordination Hub?

The Devon Care Coordination Hub is staffed by senior clinicians from interim provider Medvivo. Ambulance staff will review cases in the call stack and assign these suitable cases to the hub. They are looking for cases that may not need an ambulance or the emergency department (i.e. they have a less serious medical need) and therefore the Medvivo team in the hub can provide advice, prescribe, or refer into alternative options to the emergency department, such as primary and community care.

NHS Devon has been piloting a county-wide Care Coordination Hub since 20 December 2023. The Care Coordination Hub runs a hub-and-spoke model with the central Devon team referring into three local clinical teams.

The West Devon ‘spoke’ is managed by the Acute GP Service based at Derriford Hospital, which the Medvivo team can referred to for specialist input if a case is being considered for hospital attendance.

How does the West Devon spoke work?

The Acute GP receives referrals from the Devon Care Coordination Hub and will assess whether an alternative pathway could meet the patient’s individual care needs. The Acute GP has good knowledge of both primary and secondary care options which can often be more appropriate and could prevent a person needing to be brought to the Emergency Department.

These include Livewell’s Urgent Community Response Services, remote monitoring via the Virtual Ward, or planned care under the Medical Same Day Emergency Care (SDEC) clinics.

What are the benefits?

• Helps keep Ambulance crews on the road: The majority of calls through the Care Coordination Hub do not require a hospital attendance all together. This releases the ambulance service to attend other calls.
• Medical oversight: The Acute GP Service retain a medical oversight of those referred into the West Devon spoke. The Acute GP has a view of both community and secondary care services and can advise, prescribe, and refer appropriately to avoid the need to attend ED.
• Early intervention from appropriate community support: Livewell’s Urgent Community Response Service can attend calls at the patient’s home within two hours (who would have a considerably longer wait for an Ambulance crew). The multi-disciplinary team can conduct a review of the patient and initiate tests in their own home, such as blood tests and echocardiograms, and report back to the Acute GP.
• Holistic onward care planning: Urgent Community Response Services can call on various professionals in the team to assess the environment and the wider health and social care needs of the patient, with a focus on prevention and an ongoing package of community care.
• Right Care in the Right Place: The Emergency Department might traditionally have been the default for an ambulance call. This model aims to only bring people into the Emergency Department if they really need to. Should further treatment be needed following a visit from Livewell’s community teams, the patient can be brought into planned clinics as part of University Hospitals Plymouth’s Same Day Emergency Care (SDEC) pathways.

What has the impact been so far?

Based on modelling from NHS Devon, eight fewer people are coming to the Emergency Department at Derriford Hospital each day on average. Three of these eight are likely to have previously required admission.

Dr Birte Morris (Acute GP Service, University Hospitals Plymouth NHS Trust):

“The impact this has on the patient is significant in that we are reducing the chances of them getting more frail or vulnerable. We get better care for the patient, it offloads the hospital and actually all around this is a success story.”

 

 

 

 

Anna Fort (Urgent Community Response, Livewell Southwest):

“When we go out to these clients and when we see they really want to stay at home, it really gives a great job satisfaction knowing that we’re not only doing the best for the person keeping them where they need to be, that we can link into other professionals and help the system as a whole.”