The InstantCARE scheme is a hospital admissions avoidance model now available through practice-based commissioning (PBC) in Saxmundham, the Suffolk town where our practice is situated.
InstantCARE enables local GPs to mobilise a live-in professional carer to go the home of a vulnerable patient within three hours to prevent hospitalisation. We feel it captures the essence of PBC.
Vulnerable patients
As experienced GPs, we know that elderly patients who live alone are vulnerable to falls, neglect and poor medication compliance, and that this often results in an acute hospital admission.
A frequent example discussed at a meeting of our PBC group, Commissioning Ideals Alliance (CIA) last year, was that of a relatively trivial infection like a UTI leading to mild confusion and a little unsteadiness.
All that is usually needed, if the patient lives with a responsible family member, is to ensure the patients eats and drinks and takes their antibiotics until normality is restored.
In many cases, if the patient is admitted, they become twice as confused, increasing the chance of falls and serious morbidity. If this hazard is avoided they still have a reduced chance of returning home because, once well, the dreaded home visit from the occupational therapist (OT) has to take place.
Well-meaning and professional OTs and physiotherapists will identify the need for grab rails and ramps, and spot carpet and bathroom hazards, with the result that the patient has little chance of a prompt return home and may become depressed and 'institutionalised'.
This can be averted by the prompt installation of a carer for 72 hours to restore the patient to health with one-to-one care.
Three days is a vital lead-in time for other services such as community nurses or social workers, who may need to introduce or amend a care package. The live-in carer will contact the practice if unforeseen problems occur.
Fortunately one of the largest national live-in care agencies is based in Saxmundham. Christies Care Ltd employs 650 carers on a weekly basis. We were able to negotiate a three-day package including a short timeframe for the carer to arrive within and appropriate paperwork for monitoring medication compliance and patient satisfaction.
Restoring self-care
CIA agreed a fee of £350 per 72-hour period of work. If the patient recovers within a day or two, the residual time is set aside for restoring the patient's support network in the community and for the carer to observe whether the patient is self-caring competently.
We have an agreement with the PCT to fund the £30,000 annual cost of InstantCARE from our freed-up resources. Our proposal received strong support from NHS Suffolk from the outset and from social services, which want to see where their responsiveness to urgent need falls short.
CIA fully expects InstantCARE to be a cost-saving initiative since we should make substantial secondary care savings.
However, the patients concerned are really social not medical cases since they were successfully managed at home. Currently the hospital discharge summaries for this category of vulnerable patients look very medical and cite, for example, problems such as acute urinary infection, instability and immobility all the way up to toxic confusional state secondary to bacterial infection.
Social services will reasonably argue that these patients did require an acute medical admission. If, however, the patient is managed with antibiotics, and by pushing fluids and a diet they enjoy at mealtimes they prefer, then the situation is wholly different. At CIA the focus is on the best care for our patients, but the 'who is financially responsible?' debate will undoubtedly happen.
Integrated care
My view is that InstantCARE and similar PBC schemes that bring together care streams are a rallying call for unified budgets and integrated care. So roll on the day when the money, rather than the patients, can be moved around the system.
At present, we can only organise sending in an InstantCARE carer between 9am and 4pm, but we hope to extend this to 24 hours. GPs in CIA who do out-of-hours work could be empowered to mobilise the service outside normal hours and fax or email the patient's practice so it knows what has happened by the time it opens in the morning.
This would be a big step toward reducing unplanned out-of-hours admissions.
We are also working with our local A&E to accelerate the take-up of InstantCARE.
It is too confusing for A&E staff to have our admission avoidance scheme sited alongside them during the week. However, there is no alternative to admission on Saturdays and Sundays, so we are placing a ready and willing carer in the A&E waiting room in case a referral to InstantCARE is appropriate.
This is potentially expensive if no suitable cases appear, so we have extended the offer to all the other PBC groups in the acute trust's catchment area. Payment to CIA from other groups will only be expected if we can demonstrate bona fide admission avoidance. If this is successful we intend to offer a similar Friday evening service.
- Dr Havard is a GP and chairman of the PBC group Commissioning Ideals Alliance in Suffolk
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