Avoiding Unplanned Admissions Enhanced Service

Briefing Summary – 28th April 2014

QUESTION / ANSWER
What is the purpose of the Enhanced Service (ES)? /
  • To reduce unplanned admissions by improving services for vulnerable patients and those with complex physical and mental health needs, who are at high risk of hospital admission or re-admission.

What is meant by vulnerable? /
  • Guidance suggests the frail and elderly and those will multiple chronic conditions.
  • Children with complex needs are also mentioned in the ES, although if these are identified, it is in addition to the 2% register mentioned above.
  • Any other patient considered by the practice to be vulnerable to deterioration and subsequent admission, both of which could be avoided or delayed with proactive management of their needs.

What is the ES meant to achieve? /
  • Extend the MDT work developed while undertaking last year’s DES.
  • Identify more patients for proactive management.
  • Enable practices to invest in extra GP/nurse/HCA/receptionist time (according to need) in order to deliver the various elements of the ES.
  • Improve communication between services to prevent avoidable emergency admissions.
  • Improve communication between services to ensure that unavoidable emergency admissions are comprehensively followed up to avoid re-admission.

What is the reimbursement? /
  • £2.87 per patient on the list size as at 1.4.14 (as determined by NHSE).

What is required for this payment? /
  • To construct a register of these patients that corresponds in number to 2% of your practice list size.
  • To agree a Collaborative Care Plan with each of these patients; to ensure that the next steps are carried out to benefit the patient in this year.
  • To use MDT to stabilise their health and social care needs in order to avoid or prevent any deterioration that might lead to admission; to ensure that the next steps are carried out to benefit the patient in this year.
  • To ensure that a dedicated phone line (direct or ex-directory) is answered at all times during work hours, so that the following can be called back on the same day:
Patients on the 2% register
A&E and Admissions Avoidance Services
Care and nursing homes
Mental health and social care teams
  • To review monthly all A&E attendances and emergency admissions to establish whether:
A patient from the 2% register needs their Collaborative Care Plan refined to prevent another hospital contact.
A patient not on the 2% register now needs to go on it.
How will the patients be identified? /
  • The initial list of patients will be identified using risk stratification by 1.7.14. You will need to choose a number of patients to put on the register from your risk stratification report that corresponds to 2% of your list size.

Is there quarterly reporting? /
  • Yes, on a template developed by NHSE. The first reporting is on 31st July.
  • Please note that the CCG is requesting a few details in advance. Please see the work plan and timescales for delivery document.

Who do I contact for support? / Lesley Connaughton, Primary Care Development Manager