Frequent Caller Project Update October 2015 – October 2016
The Welsh Ambulance Services NHS Trust (WAST) is committed to providing a patient-centred and clinically appropriate service to the patients it serves, ensuring the right response to the right person at the right time.
Many of our patients rely on the 999 service we provide for an emergency response to serious and life threatening conditions. The majority of patients can be treated in line with Trust clinical systems such as Paramedic Pathfinder, Manchester Triage and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines. In addition, there are 24-hour nurse triage systems where patients are assessed by hear and treat clinical assessment.
A number of patients in Wales repeatedly access the 999 emergency ambulance service, when an alternative care pathway may be more appropriate. This patient group often has complex health and social care needs and may have disengaged from appropriate care services.
Unnecessary conveyance to hospital will also place increased pressure on NHS Wales. Health Boards fund emergency care provision via the Emergency Ambulance Services Committee arrangements. Frequent callers receiving multiple ambulance responses do not represent the most effective use of resources.
Reducing demand on the ambulance service under step 1 and providing the right service at step 2/3 are key elements of the ambulance care pathway. Improved frequent caller management will ensure that WAST and NHS Direct Wales (NHSDW) resources are used wisely.
Some agencies (both public and private) may have policies and working practices in place that result in an over-reliance on the ambulance service. Common examples of this may be care homes without appropriate lifting equipment, sporting venues without appropriate medical provision and a minority of healthcare professionals who rely heavily on the ambulance service.
Clinical Support Officers (CSO) within the Welsh Ambulance Service were tasked to manage these patient groups in 2013. The team takes a multi-agency approach in order to manage the WAST response to an individual or agency towards reducing call volume, whilst ensuring the optimum care pathway for the patient involved. In 2015, frequent caller management was identified as a standalone project under the Step 1 – “Help me to Choose” work stream of the Welsh Ambulance Service’s Clinical Modernisation Board.
The following graphs highlight the work of the CSO team commencing October 2015. To be able to measure the impact of this team and its collaboration with local health boards and other agencies, it was decided to measure the frequent caller over a 4 month period.
A frequent caller has been identified nationally by Frecann (Frequent Caller National Network) as a person who contacts the ambulance service more than five times in a month or 12 times in three months. Each month, the CSO, using the WAST Frequent Caller Policy as guidance, identifies new patients who meet this threshold and begins working with the patient and other agencies to seek clinical solutions.
Each set of graphs contains a new cohort of patients; there is no duplicate reporting of a patient in those graphs.The patients are all managed in line with the frequent caller management process map attached at Appendix A. There are 3 stages to this map, which takes approximately six months to navigate where there is entrenched behaviour.
Stage 1 involves the CSO identifying from WAST data the frequent caller and beginning the interaction process with the local GP, or they will send the patient a letter to highlight that their need may be better met with alternative services which are available. The vast majority of frequent caller activity can be resolved at this step, by early identification and better signposting to these agencies, where increased care packages of support and care will be provided.
Where there is no improvement in call volume at month three, the CSO will ask all agencies to be involved in a multidisciplinary team meeting aimed at further attempting to identify the unmet need of the patient and develop an appropriate care plan for agencies to use to better manage the patient when they interact in the future. This plan is then used by a clinician in the Clinical Contact Centre. They will review the patient and their clinical need using a “hear and treat” system called Manchester Triage. They will then send an appropriate resource if required and refer to a suitable agency highlighted in the plan. The patients call activity will be reviewed the following month, with the hope that the call volumes reduce.
Stage 3 of this policy usually covers months five and six. To date, there have been six patients in Wales who have triggered these stages. Quite often at this point, the behaviour of this group of patients has become entrenched. A further multi disciplinary team meeting will be arranged, often with representation from one of the Welsh police forces. This can provide appropriate support and guidance to this team as to whether we should be progressing this case via the judicial system to seek support in identifying the solution. Over the period of this report, four patients have received custodial or suspended sentences for their behaviour, which magistrates identified as a waste of tax payers’ money and behaviour that puts the lives of others at risk.
The following graphs highlight four months of activity for a group of new patients, the numbers of calls they have made and the number of hours of ambulance resources which were dispatched to scene to manage the 999 call.
October 2015- January 2016
November 15- February 16
December 15-March 2016
January 16-April 16
In March 2016, the frequent caller reports became automated; they are set out slightly differently, as seen below, but still capture a new group of patients.
|
All Wales |
Mar |
Apr |
May |
Jun |
Total |
|
No. of Frequent Callers * |
96 |
47 |
41 |
41 |
- |
|
Total Calls |
633 |
185 |
158 |
156 |
1132 |
|
Total Responses |
892 |
255 |
218 |
181 |
1546 |
|
Total UHP (Hours) |
753.9 |
191.0 |
186.5 |
140.9 |
1272.3 |
April 16 – July 16
|
All Wales |
Apr |
May |
Jun |
Jul |
Total |
|
No. of Frequent Callers * |
76 |
50 |
33 |
32 |
- |
|
Total Calls |
533 |
327 |
299 |
269 |
1428 |
|
Total Responses |
815 |
555 |
441 |
368 |
2179 |
|
Total UHP (Hours) |
581.7 |
348.4 |
227.7 |
182.5 |
1340.3 |
May 16 – August 16
|
All Wales |
May |
Jun |
Jul |
Aug |
Total |
|
No. of Frequent Callers * |
62 |
33 |
26 |
28 |
- |
|
Total Calls |
429 |
140 |
102 |
97 |
768 |
|
Total Responses |
617 |
167 |
145 |
157 |
1086 |
|
Total UHP (Hours) |
465.1 |
131.5 |
112.7 |
114.2 |
823.6 |
June 16 – September 16
|
All Wales |
Jun |
Jul |
Aug |
Sep |
Total |
|
|
|
No. of Frequent Callers * |
61 |
34 |
23 |
22 |
- |
|
|
|
Total Calls |
388 |
137 |
88 |
84 |
697 |
|
|
|
Total Responses |
549 |
185 |
142 |
130 |
1006 |
|
|
|
Total UHP (Hours) |
403.1 |
151.4 |
131.4 |
105.2 |
791.2 |
|
|
|
|
Frequent Callers |
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Improving the Trust’s response to frequent callers is demonstrating a reduction in the number of calls received and ambulances dispatched to these patients. More importantly, the multi-disciplinary approach taken to support patients results in better clinical solutions for them. Examples of this include:
Patients are supported in partnership with the patient’s GP, specialist services, the police and local authority partners. This joined up approach often identifies unmet healthcare needs, which influences their subsequent behaviour via the 999 system. Through this work, the Trust is using its unique position as the only 24-hour national provider of emergency care in Wales to benefit patients and the NHS. To date, a total of 639 frequent callers are being managed by the CSO and health board partners These patients’ combined calls to WAST totalled in excess of 3,800. A total of 3,209 unit hours (a unit hour is one hour of ambulance time) have now been saved as a result of seeking patient-centred solutions to frequent caller needs. The saving to WAST and NHS Wales is in excess of £500K. The CSO team will continue to monitor these patients, escalating care where required. This team will identify 10 new frequent callers every month in each health board area.
There are now more than 30 patient-specific directives which have been designed in collaboration with health boards and local authorities. These form a plan for all agencies to use in the event of a call from a frequent caller. This plan is developed with the full knowledge of the patient. These plans are then utilised as part of triage by clinicians in the Welsh Ambulance Service’s Clinical Control Centres. Since these plans have been provided, we have seen a reduction in the dispatch of ambulances to these patients who are now being managed differently as a result of these clinical plans.
In September 2016, this piece of work was recognised by NHS Wales and received two awards; one for working seamlessly across boundaries and the other for outstanding contribution to delivering prudent healthcare. |
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Nursing Homes
The next phase of the frequent caller project involves working collaboratively with our colleagues in the nursing home sector. This approach is supportive, educational and looks at providing solutions for some homes which may have been identified by the CSO and the nursing home data which is provided to him on a monthly basis.
To-date, two health boards in Wales have provided funding to purchase valuable equipment for nursing home settings, highlighted in the images above. 999 calls for falls and cardiac arrest are two of the most common calls to nursing homes. It can be seen from the data provided that up to 20% of 999 calls to these locations do not result in the patient being transported to hospital. To address this, the CSO works closely with the matron or manager of individual nursing homes to review call volumes and address calls that may not have required an ambulance response.
This is supportive and is often explained by providing posters for staff to use when deciding, when to call for an ambulance and what type of ambulance response will be suitable.
This is an ongoing piece of work and we will soon be in a position to compare call numbers pre and post implementation of equipment designed to reduce call out. Also we will be able to compare pre and post visit by the CSO to review call volumes.
Ends/RP/EVH/Oct16