KISS: The Unplanned Admissions ES for England

KISS Guide to the Unplanned Admissions Enhanced Service for England

Proactive Case Finding and Care Review for Vulnerable People

The Unplanned Admissions Enhanced Service is now upon us. It replaces the work of parts of QOF and the QP domain. It also replaces the Risk Profiling Enhanced Service, but it builds on this concept so that the ideas and work that needs to be done are not be entirely new. The BMA have produced an excellent BMA Guide for Practices, and we summarize the main points below.

Templates for care plans, letters to patients etc. are available to download (these are optional, you can use your own)

Why are we doing this?

It may be called ‘avoiding unplanned admissions’, but the subtitle ‘proactive case finding and care review for vulnerable people’ really defines our role. There is general consensus that to avoid unplanned admissions requires a system wide approach that co-ordinates social care, community nursing, rehabilitation and NHS 111. For case management to work and reduce admissions all these components need to be in place,  Kings Fund Report on Case Management. We are an important part of this picture, but only a part, and our role is to explicitly identify our most vulnerable patients and to optimize and co-ordinate their care.

What do practices need to be doing now?

• Establish the at-risk ‘case management’ register
• The 2% of the practice population aged over 18 at highest risk of unplanned admission
•   CCGs should provide GPs with a risk stratification tool to do this, but if not available practices should use clinical judgement
• We would recommend the QAdmissions tool as this is the best research validated   tool. It can be integrated into any GP system and costs c. £600 per practice. (please note that NB Medical has NO financial interest in QAdmissions or any other tool)

•  Inform patients that they are on the register & of their named accountable GP and care co-ordinator
• The named accountable GP will have the responsibility of developing the care plan & appointing the care co-ordinator
• The accountable GP will be responsible for the patient’s care but patients should be reassured that this GP is not their sole care provider and that they will continue to see other members of the team as they currently do
• The care co-ordinator will be the main point of contact for the patient & also check the care plan is being delivered. This could be a clinician, practice nurse or community nurse
• Patients need to be informed by the end of July 2014 (unless patients aged over 75 have already been informed of their named GP as part of the 2014 GMS Contract Changes)

• Ž Put a personalised care plan in place
•   By the end of September
• Optional Templates are available and the BMA Guide for Practices indicates the key details that need to be included which include
• The key biographical information, the key people involved in care, key relevant medical information, individual preferences (e.g. end of life wishes) and key action points (e.g. early signs of deterioration with agreed action plan)
• Note that if a patient has dementia, serious mental illness or learning disability they should already have a care plan in place

•  Offer a by-pass number for other care providers
•  Available for hospital, carers, nursing homes, paramedics etc. to use for urgent matters

•  Offer same day telephone access to patients on the register with an urgent problem
• Which we would be doing anyway...
• 
  
• Follow-up patients on the register following discharge from hospital
• Ditto…but follow up within 3 days of the discharge note being received

• ’ Regular review of emergency admissions & A&E attendances of
• Patients on the at risk register on a monthly basis
•   Patients from care and nursing homes should also have their admissions reviewed (practices with large numbers of these may look at samples and negotiate the terms of this locally with their Area Team)

• “ Complete a quarterly report
• To be submitted to the Area team and CCG each quarter
• Payments will be based on a maximum of £2.87 per registered patient (i.e. so for a 10,000 patient practice it will be worth nearly £30K pa), 45% upfront and the remainder based on the quarterly reports and an additional 15% end-year payment for undertaking regular internal review of all unplanned admissions for vulnerable patients
•  See the BMA Guide for Practices for payment information

It is clear that most of the work will be in identifying the patients, setting up the care plans and reviewing admissions. This is a lot of work, and the care co-ordinator role will be key to manage the workload. Although the concept is new, it formalises a lot of the core, traditional values of General practice: maximising continuity and co-ordinating care for our most vulnerable patients.

Good luck!!

Simon & the NB Team