Transcript: ASSET (Age Specialist Services Emergency Team)


ASSET, which was set up in February 2012, is based in Coathill Hospital in Coatbridge. The team is running a Hospital at Home service for people aged over 65 (sometimes they take younger patients too)

Podcast Episode: ASSET (Age Specialist Services Emergency Team)

Category: Adult social care 

Speaker(s):


What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

TM - Trudi Marshall

ASSET, Age Specialist Services Emergency Team, was set up in February 2012 and is based in Coathill Hospital in Coatbridge. The team is running at Hospital at Home service for people aged over 65. Hospital at Home is for people who require secondary care but who are cared for at their home or the place in which they normally live, rather than having to be admitted to a hospital ward. In this service, the ward is taken to the person's home and they are discharged from their home and not from hospital. Trudi Marshall, a nurse consultant for older people within NHS Lanarkshire, works with ASSET and came to speak to us about her experiences.

TM Lanarkshire has a population of around 562,000, the catchment population for the hospital home team that we were looking at was around 185,000, so it was around one of our district general hospitals, we have got 3 district general hospitals. Looking at that population, our over 65 population was 27,551, but within the area we are looking at, it's on that map, it's Airdrie, Coatbridge, the north, we have got high areas of deprivation, so what you sometimes see is 60 year olds, late 50's, with high levels of frailty, much earlier than you would normally see them in. And normally in some of the other localities when we are targeting care of the elderly services, we would target 75 upwards, but for this locality it was definitely 65, and we have taken some younger because of the frailty that they have displayed. The hospital home team as well, when we were setting it up we were quite aware that there is a range of community services already available, you have got community nursing, long term condition management, a lot of good third sector services around, so it wasn't about setting anything up completely in isolation, it was about trying to set it up and link it in with as many of the existing services that we have got. So it was a complete picture that could be used to support people rather than just something stand alone. To a certain extent, it's still sitting slightly standalone than completely hooked up, and I think that was just a timing thing. We were one of the first hospital homes in Scotland and I think people struggled to get it initially, so other services weren't quite sure how we'd link in, so when we originally approached them it didn't work out the way we would hope, so ... but now I think they have got it and they are starting to build up their community services following on from reshaping care, so I think it's just making sure that we have got the community links built back up there. And really one of the reasons we wanted to do it was looking at hospital care for older people and knowing that most people viewed it as a place of safety, that if they got the older person to a hospital it would be viewed as a place of safety, but we knew that that necessarily wasn't the case and actually there was some evidence, early evidence from Sasha Shepherd's Cochrane Review that hospital home might actually be equivalent or safer than hospital care for when you look at frail, older people.

And this is just some figures around risks for older people.

  • Hospital acquired infection, you have got a 10% risk.

  • In hospital decline in function, 12% risk. And again that's because when you come into hospital the first thing you will be given is a hospital bed and the majority of time you are changed into your nightwear and you are suddenly infirm and placed in bed.

  • Elirium, 3 to 29%, and that's probably a low estimate. A 28 bedded ward probably experiences around 10 falls per month.

  • 1.8% harmful medication errors. And in the NHS board, we are probably getting about 28 complaints per day, is probably about the average. So we know that it's not a great experience.

So the hospital at home wasn't set up to prevent avoidable hospital admissions for people that we didn't actually think required hospital, it was set up for people that we felt actually required hospital level care, they actually required the resource of the specialist team within the hospital, but it was providing that hospital care in a different way to take away those risks associated with it, and that it would be for a very short and limited time. So it wasn't around early supported discharge or community rehabilitation or just enhancing those teams a wee bit, it wasn't an enhancement to primary care, saying to GP practices, well if you just did a bit more you could keep more out of hospital, it wasn't around chronic disease management, it was around acute phases of illness that would normally access a hospital and just trying to provide that hospital in a different way.

So the ASSET Pathway, our inclusion criteria was basically anybody over the age of 75, we started with initially, and nursing home residents of all ages. We changed that, as I say, down to the over 65's and we have had people as young as 40, probably, on the service now, where, for various different reasons they have got multiple long term conditions and they are frail. So we have had some MS patients on, we have had some younger patients that are end of life but have taken something acute, and for whatever reason the GP and the family has not wanted to use the hospital, we have had some bariatric patients on who have had very horrific experiences of leaving the house to try and access hospital services, and again the GP's have contacted us to say, we know this isn't your usual client group, but could you do a domiciliary review and advise us if hospital admission is definitely needed before we proceed down that. So we have had a few different areas that we have been involved in. Mainly we had an exclusion criteria and that was stroke, because the evidence base is that the best care is within a stroke unit. Chest pain, so acute coronary syndrome, DVT, again we have got really good established DVT pathways that are out patients, so they wouldn't need us. A clear fracture and clear surgical, and as I say, the younger age range was accepted if frail. We don't take surgical admissions, but we have actually had the surgeons phone us direct from the hospitals a few times to say they have had GP's phone in for their expected and it's maybe a 94 year old with an acute surgical abdomen and just before the person goes through a hospital admission surgical review in an A&E department, could we go out to the house and check that that person would be for intervention, so that you are not taking in a 96 year old person with advanced dementia, that the surgeons and an anaesthetist would never actually touch, so that we could have that sealing of treatment conversation in the house with the family and everything. And that's actually worked out okay. In some instances we have been able to say absolutely this person is for surgical intervention, we have actually started the ball rolling, we have did your clerk and we have did your bloods and they are coming into you a bit more prepared, or actually, no, we have had the conversation and actually we are going to take them on and we will manage their symptom control and get them established with community services. So it's worked out quite well.

The team is a multi disciplinary team, so we have consultants, we have nurses that have been trained with advanced clinical skills, we have AHP's in the form of OT and Physio, who again have been trained in advance clinical skills, we have a CPN, we have admin and clerical and we have clinical support workers ... level 4 clinical support workers, that again we have given some advance skills to, and they cover the HP's as well, so they are generic workers that cover all the professions.

So Band 4 is just one down from a Registered Nurse, so it just means that they are expected to do some more clinical skills and they have been given some additional training.

So just to talk you through what ASSET actually does, we use a case study, just because it's a bit easier to show the old pathway and the new pathway, so this was an actual patient scenario that came through ASSET, but it's an 80 year old man, he lives with his elderly wife, bedroom is upstairs, he has got multiple pathology, known congestive heart failure and he is presented with breathlessness. In a normal pathway, probably in the morning if somebody is not well, generally the family are phoning into the GP's first thing in the morning, if they have managed to survive overnight. The GP's maybe been involved in the care, they have got a chest infection, they have got uncontrolled atrial fibrillation, which is just irregular heartbeat, which can be brought on by infection or heart failure, and unable to walk more than 6 metres. So the person would normally phone the GP, the GP would decide this is outwith what I can manage in community, I am actually wanting to admit this person to hospital, and the way they would do that is they would phone, what we call the Emergency Response Centre, which is our one point of contact for all emergency admissions to hospital, and that person books them in an ambulance and books them into the hospital bed, if you like. So it lets the hospital know you have got a patient expected and the ambulance has been arranged for 2 hours, 1 hour, 4 hours or whatever, so the hospital knows roughly when they are going to come.

When they arrive at A&E or an assessment area, they are seen by the triage nurse, who will do the initial assessment, observations, gather a social history, speak to family. They will then be seen by a junior medical doctor, who will again gather a clinical history, a social history, they will undertake an initial physical examination, will probably order your initial investigations, so bloods, chest x-ray, ECG, and all through this the person is on a trolley, either within an A&E department or emergency receiving unit. Probably a bit later on in the day, so looking at the timescales from that 9 o'clock when they contacted the GP, we are probably hitting early afternoon by now, to late afternoon, they will be seen by a more senior medical staff who will do probably a slightly more targeted clinical assessment, but they will be double checking on that juniors assessment at the same time. They will make sure the initial management plan is in place, any initial treatment, and they will start to think about transferring the person to a bedded area. Now bearing in mind when you say to an older person at 9 o'clock in the morning, you are going to hospital, the bag is packed, the family is sitting, if they have got an elderly relative, jacket on, terrified to go to the toilet in case the ambulance comes. So you have got all that stress and this is now kind of late afternoon. Then later on that evening they will probably see the consultant, the case will be presented, they will decide that they are on the proper management plan. If they are going to allow somebody home they will start to think about it, but by this time you are hitting late afternoon, so then you are thinking, well they are elderly, they had difficulty mobilising before they came in, what's their functional assessment, can I get an OT, can I get a Physio? There are some ongoing medical issues, can we get them stabilised right now, transport, if there's any medication changes, trying to get them, so it actually all starts to run away with you and before you know it, you can't get this person home, even if clinically you think that they are medically stable. What then happens is, most hospitals will go to some form of medical receiving unit and then from that medical receiving unit, if it's decided that they're care of the elderly and they are frail, they will go to a care of the elderly specialist unit for comprehensive geriatric assessment. Our length of stay in Lanarkshire is probably around 10 to 12 days for an older person, and that's because if they had had services as well, you have got services being suspended, then trying to re-start them and then trying to book transport, and invariably once you get them into that hospital bed then you run all the complications, so you start to get the muscle wasting within 24 hours, they start to get frailer and you are just fighting an uphill battle, so which you could have got them home on day one for, you suddenly run into 10 days.

So what we were trying to introduce was a different pathway, so again, 9 o'clock, wife worried, phones the GP, the GP calls the ERC in exactly the same way, we had to make it as simple as possible for the GP's because they won't do anything complicated, it needs to be one phone call. So they do the exact same phone call. But rather than them booking the ambulance and phoning the hospital, they phone ASSET instead. So we have given them that criteria and we spent quite a lot of time working with the ERC staff, and they have come out to the team and spent some time so that they get a real feel for the types of patients we were trying to capture, so it wasn't just on paper. So they can have the conversation with the GP and say actually, this patient sounds as though they might be better assessed at home, can I get the ASSET team out. Initially there was a reluctance, but as we started to build a reputation and GP's tried it once, had a successful case, now in most cases they are asking for us directly. An ASSET practitioner, so initially we will send out our Band 4 practitioner. The Band 4 will generally be in the house within half an hour, so if you think of all that timeframe before, we will have somebody in the house within half an hour. They will do a 12 lead ECG, they will start the admission process, gather in the functional and the social history and they will do all the bloods. They will take those bloods directly to the labs so that the analysis can get started straight away, we have then got to a Band 6 practitioner, whether that be a nurse or AHP, they all go in and they all basically do that FY1, that junior medical assessment, so they will do the full clinical examination, the full medical history, all the observations, the social, they will do an initial differential diagnosis, and they will do a management plan and start to initiate that management plan. At any time, any member of staff can escalate up, so the Band 4 can escalate to the practitioner and the practitioner can phone the consultant and say, I want you here in 5 minutes, move, or this one is actually okay, that other one, I know that there's a more serious call come in, so they can do a bit of triage and manage that. And again we have got IPads and things like that, so we if we do an ECG and we think I am not really sure, I think the person has went into full bundle branch block, but I am not sure, you can take a picture of it and send it directly to the consultant, so that the consultant, en route can see and actually say, right this is what I want you to do. So we have got that that's going on. The practitioner is generally there within an hour, we aim to be within an hour and we meet that probably in about 90% of cases. The consultant then comes in within 2 hours, so again that phone call is at half 9, we will have everything done and dusted by half 11, whereas it's still been going on to evening in the hospital. Everybody is seen by a consultant, we have got some practitioners now that we are confident enough that for certain cases, particularly COPD patients or care home patients, that the consultants have said if you are happy and content that you have got the management plan appropriate for that, then you just need to discuss it with me and I don't need to come out and review. So we are seeing a few years down the line that we are starting to reach that stage and we knew it would always take us a long time to reach that. So the consultant will see, they will decide whether things like ultrasound, CT scan, X-rays of abdomen and things like that are decided. Generally a practitioner will decide on a chest x-ray, but we don't normally send somebody up that day for a chest x-ray, we don't use them as much as you would, every single person coming into hospital gets a chest x-ray done, but what we have found is we don't use them as often because you are actually thinking, rather than just ... that's the normal that you get if you get admitted, actually is it actually clinically required, would I do anything with the results, is there indications that you should have it done? So the consultant will do a whole review, and generally that person's family is with them the whole time as well, so they are involved and it's undertaken within the house and we just follow into a management plan.

We review the cases every day, so we have got a big screen now in the room and it's like a virtual ward, if you like, so we have got all the patients names on the board, all the management plan, everything that we are doing with them and we do a ward round every day with a consultant, and we decide this is a management plan, this is their new results, this is what's happening and we develop a new management plan, and we just manage them for their length of stay on the team. We liaise with Home Care, any other community services, family, and as soon as we think that that person is over that acute phase, then we will pass back over to GP and to community teams. The average length of stay on the team is roughly around 4 to 5 days, I think it has crept up slightly just to about 5 days in the last analysis, but it's stuck roughly around 4 days, so a shorter length of stay.

But the big question, is it safe and is it effective? Because as I said at the start, there was only Sasha Shepherds work, there was only kind of one Cochrane review, and there wasn't any large study, the full review covered about 500 people, I think, so it wasn't huge, and some of it was for COPD patients, some of it was stroke, so there wasn't any kind of big study looking at frail, older people. So we were really keen when we went into this, we were all willing to take a risk and try it, but we were really keen to try and make sure the big question was, are we killing more people than hospital really? So we were wanting to look at mortality rates and make sure that we weren't putting any more people at risk than would normally die from being at hospital, so we were really keen to look at it.

We have analysed roughly just under 2,900 cases now since we started over the 29 months, and what we have found is 76% of them, of all the cases that have been referred, 76% of them we managed to keep successfully at home, so roughly overall managing to keep them at home and deliver that hospital care at home, so they would have normally have been in hospital. The break down is roughly 50% for the female, 41 sorry and 59 for the females.

Initially as well we thought that all these frail people would be known to DN's, that a lot of them would be on DN's case loads through care management, through long term conditions, but actually only 13% of them had been known to district nurses, and a lot of them weren't known to Home Care and other services. So we were surprised by that, but I think because this is potentially an older age group, that yes, they are frail but they are managing fairly well with family support, community support, third sector, until they take an acute illness, and that's when they take a sudden dip. So they are not generally housebound by DN's standards.

The length of stay, as I say, it's went up slightly, 5.7 days, and as I say only 19% were known to social work.

The 30 day mortality rate that we looked at for our patients is 8% and certainly when we initially started, I think acute hospitals was around 12%, but I think it's roughly now around 9% the last time we checked. It's difficult to get the acute hospital mortality stay for that group, so we reckon we are certainly no worse, so we are not doing any harm more than hospital admission and it might be slightly better, but that might be explained because obviously the cohort, if we are admitting 24% of the patients we see at home, then we will probably be admitting the sickest to hospital, so it might be a slightly, although still acutely ill, weller cohort that we are keeping at home.

Across the sector, certainly the Lanarkshire sector that we have been operating in, we have managed to close 50 hospital beds. Now they are not acute hospital beds, they are our community associated site hospital beds. We also regularly look at the workload for care of the elderly within the hospital, and previously when we were going into the emergency receiving units, screening for frailty, we were probably finding around 17 or 18 patients per day that required care of the elderly, and then we would be struggling to find them beds and appropriate speciality, you couldn't get them beds and we know that that has worse outcomes for the patient, so since we introduced ASSET, that number at the front door has decreased, so we are probably seeing around 40% of the speciality work now within a community setting, so we are starting to see that shift. We have had a quality revaluation undertaken by the University of the West of Scotland, it was a small in-depth, I think it was 8 patients and carers that they interviewed, but it was fairly in-depth interviews they undertook with them, and overall it was a positive experience for the patients and the carers. We were also worried that we would cause significant carer strain, but I think we had probably underestimated the carer strain of somebody being admitted to hospital, so most of these people had previous hospital admissions and when the carers were comparing it to the previous hospital admissions, they were finding that this was a much better experience. I think they still felt in control, the person still felt in control, it was different dynamics when you were in the house, whereas in the hospital setting, everybody was out of their own environment, their confidence was reduced, so their level of empowerment through the whole experience was reduced, so that came across in the interviews.

And the financial evaluation is probably the area where we are lacking slightly. We have not had any finance people had the facilities to work with us, so we have just been kind of doing it on the back of a fag packet, as the best we can, is basically the best way to describe it, and certainly it looks as though for every pound you spend in ASSET you are saving kind of £2, so ... that's the way it looks.

We basically started, in what could only be described as a cupboard. We had one desk and about 7 members of staff. When you were doing a ward round, you had to stand up and do it off a sheet of paper. We are now in a fairly large room, you have seen it, and we have got, again we started with white boards, we have got virtual screens now, we have been working with New Genesis and it's ... Care View it's called, so we are able now to track everything electronically, we can generate task lists, and hopefully once we get the 3G sorted, that will be transferred electronically out to the staff on the road.

We are starting to see a lot more specialist trainees come through the service, they are requesting time in community settings, and we have actually, most of the consultant appointments that we have managed to steer from Glasgow recently, they have negotiated community sessions within their contract, the only way they would come and work was if they got a chance to do community sessions, rather than all hospital based work. So we are starting to see a shift in that as well.

We have also got 2 ambulance practitioners now from Scottish Ambulance Service, who have been working with us, they have been working with us for about a year now, primarily it was initially to train them up to that kind of being able to work at that junior medical doctor, and the idea was then that they would support the ambulance crews, but what they are saying is, actually they wouldn't just be able to support the ambulance crews, they would still need the links to the acute hospital site and the consultants because they are seeing the complexity of the cases, the frailty, the co-morbidities, the medication issues, they couldn't possibly know it all, so they are wanting some continues peer to peer support, so we have got a meeting tomorrow to look at actually how we support them to go back out to support the ambulance crews, because they have really been working within the team and they are probably going to work backshift to nightshift, if you like, support the ambulance crews over that out of hours period.

The SMR1 reporting, we have been working with ISD, although it's not called that any more, but I can't remember what they are called now, but ISD, and basically the SMR1 reporting is the reporting that the acute hospitals provide on all their coding and activity and it allows you to pull off things like length of stay, mortality and things like that. We've not had that at hospital and home, but now we have been working with ISD, and that's it online now, so we are getting SMR1H, I think it's called, and that's for Hospital at Home, and it's so that we can be compared in exactly the same way as you would a hospital stay, so that we can be held to the exact same standards on the analysis. So that's available now for Health Boards, but it's on a voluntary for the next few months until they check the data and make sure that they can analyse it in the same way and that we are all collecting it in the same way and then it's going to be compulsory, probably from June next year.

Graham Ellis, one of the consultants, he's been working with Sasha Shepherd, and we have got funding now for an RCT, which is multi site, so there is going to be 2 centres in England, 1 in Wales and we are going to have 3 in Scotland, so we are going to have Lanarkshire, Fife and Lothian, which is really good. So quite a lot of funding comes with that, and I think we are going to recruit for 2 years and then the follow up will be for a further year, so I think that will finally answer the question over, does hospital at home provide a viable alternative? It's going to look at finance as well and going to look at all the patient and carer issues as well, so it's quite an in-depth study.

We are now doing things, O2 prescribing as well in the community, and we are starting to look at IV therapy, certainly the Hospital at Home team in Fife and Lothian are already doing IV's, but Lothian are only able to do it, it's their consultant that's doing it, so what we are trying to do is, we are working with the community nurses locally, so that the whole community nursing workforce is upskilled to be able to give IV's, and then if we identify patients for IV's, they would be able to continue with it, and that way it would support the hospital admissions as well, rather than us being a Super Team that comes in, does everything and back out again, so it's around developing the community nurses.

And that's just our board as well, as well as holding all the patient information when we go to it, when we actually get a call in now, we can actually pull up the street and look at the street and you can't quite see in the persons house to see them, but hopefully once their IPads are connected to it, you will, because you will be able to do that face to face with the consultant, and hopefully that will work out.

So our cost for the staff, we have 14 consultant sessions, we have a Band 7 practitioner, 3 Band 6 nurses, a Physio, an OT, a CPN, a clinical support worker and 1.3 whole time equivalent CNC, and for a year that's around £600,000, but when you look at the cost of hospital bed, the 50 beds that we have closed equates to £2 million, and that's our cheapest bed rate rather than the high, but based in mind the patients that would have went through those beds would have went through an A&E, an emergency admission and an in-patient episode. So as I say, for every £1 invested, we are probably saying, you know, save you £2. And when you look at the value of the equivalent patients in a ward, we are probably saving quite a bit there. They value ... our probably cheapest ward, we run, in ASSET, with an average of around 24 patients at any one time, we can have slightly quieter periods and we can have quite busy periods, but for £600,000 we are running with about 24, which is the equivalent for a ward, and when you look at the cost for our wards, our cheapest ward, you are probably around £800,000, and that's not taking into the account the AHP sessions and the consultant sessions, that's only the domestic and the nursing in the building sessions.

We have also tried to look at our over 75 admission rates and we have tried to compare this, it's really difficult to compare, so what we tried to look at is all the localities in North Lanarkshire, so we have got 12 localities in Lanarkshire, and we tried to look at the re-admission rates, and their re-admission rates were sitting about 11.7, when we narrow that down just to the localities that ASSET covers, it's only sitting about 1.3%. Sorry this isn't the re-admission, this is the admission rates, so the admission rates ... and we also then tried to split it into the 3 district hospital, so the one that ASSET covers is Monklands Hospital, the middle one, what we are probably seeing on the other 2 sites is there has been consistently an increase in the over 75 admissions, Monklands it was tending to come down, but we have went up again, so that's why it's so difficult because it's so variable and it's so multi-factorial to look into why the reasons are, so we are trying to look at that in various different ways.

We tried to look as well as, one of the reasons why we are doing Hospital at Home is we know that if you are admitted to hospital you have a significant risk of ending up in care homes, and we know that if you are admitted to hospital and you go to Care of the Elderly specialist, and are cared for by Care of the Elderly, that risk reduces, and that's what we were trying to replicate in the community, is that same thing. So we tried to look at admissions from care home for the localities that ASSET covers, which is the top graph, and then admissions to care homes from the other localities, and you can see the difference as well. But again that could be those individual localities are doing really focused community work, so you can't necessarily say that that's definitely been us that has been the cause of that, it could be other re-shaping care work that's going on.

One of the things that when we were starting Hospital at Home as well, we were looking at how we developed the practitioners, where we recruited the practitioners from and how we developed them. So when we first started, me and Graham had a really, really gaff presentation, is the only way to describe it, where we went to all the localities and we presented the team that we were wanting to set up and the type of staff that we were wanting to recruit and how we wanted to develop them. At the time there was a lot of friction between primary and secondary care because this was a secondary care project, primary care wasn't happy that it was a secondary care project and it was coming out to primary care, and we were being met with quite a lot of resistance saying ... community nursing, long term condition nursing, already does this, GP practices already do this, they don't need it, and what we were trying to show was that there was, it was about hybrid development of pulling together. So we put up this slide of Robocop and had said, it's about this hybrid development and all this different arsenal of tools and different skills and it went down like a lead balloon, so I am now known as RoboNurse. So that definitely went down like a lead balloon. But what we were trying to say, it's about taking staff from different backgrounds, they have got different skillsets, they have got different experience and then building individualised learning programmes for them and developing their skillset up so they could support this. And that's what we done, we employed nurses from a range of backgrounds, and doctors, and AHP's, so some of them did come from acute, but it wasn't ITU, it was acute care of the elderly, so it wasn't ... some other services have only taken ITU nurses to work at their Hospital at Home. We employed some community nurses, we employed some rehab nurses and we employed AHP's from either hospital or community settings. So we picked them from a variety of backgrounds, and what we were trying to say is, we are not trying to develop advanced nurse practitioners, as such, because that's a whole different role. What we are trying to do is just develop one area of your practice and build that up. So that's what we focused on. So it was trying to get the expert knowledge base, complex decision making skills and some clinical competencies. What we were trying to say is that that advanced practice is a level they practice rather than a particular role, so it wasn't saying that they are coming into this advanced nurse practitioner role and they are all going to be all singing, all dancing, it was just around that development of the skillset.

And the level we were aiming for was probably, this is the Skills Framework, you have probably seen this, is between 6 and 7, so the senior practitioners to the advanced practitioners, and on agenda for change, they were going to be employed at Band 6, and that would allow them to continually develop. So it's not to say that they might not develop into advanced practitioners, but we weren't looking to develop fully advanced practitioners.

The area, this is the practice themes from advanced practice and the only area we were really looking to hone in on was the advanced clinical practice, that was the bit we were picking up in. So we weren't necessarily looking at developing leadership skills in this group, although they might develop it through time or the research, it was only in that advanced clinical practice. And that's just giving you, narrowing it down to the advanced clinical practice, when we were looking at the staff we were going to recruit, this is the type of things that we were looking for them to do. So take the history, carry out the physical examinations, expert knowledge and clinical judgment to potential diagnosis, refer for investigations, make a final diagnosis, carry out treatments, prescribe medication, refer to other specialists, plan and provide care involving other members of the team, and make sure that continuity care and follow up visit, and work independently and just supervise the rest of the staff. So just those skills.

We looked at the competency and capability frameworks that are around and there was nothing specifically that was going to meet our needs of how to do that, particularly within a community setting. Some of the frameworks had some of it, but they were generally tailored to hospital settings where you had a lot more supervision.

The other thing as well is that we were looking at new ways of working, delegation of roles, so from consultant straight to a nurse, rather than through an FY2, FY1, the new roles and the skill sharing as well across disciplines, so it was getting the HP's to do this as well as the nurses and getting the nurses to do functional assessment. So it was focusing on the right person, the right thing, the right time, doing it the right way.

The Joint Improvement Team gave us a small amount of money and we entered into a collaboration with the other 2 teams to try and look at how we were developing our staff and pull it together, so that other areas could look at it if they were thinking of developing Hospital At Home, and what we developed is a competency skills development for staff, and the competencies within this, there is a huge amount of competencies within this, and the reason we included them all, was that if an area was thinking of developing their Hospital At Home, they might be tailoring it specifically to their locality, so they might not need them all but they could pick and choose which ones were appropriate. And we are actually doing a piece of work just now, where we are looking at within the team, how we develop our Band 5's, within the team, we have got a Band 5 nurse working with us at the moment as well, just through some additional funding. We are looking at how do we actually develop them, what's the Band 5 role, and what we are doing is we are looking at all these competencies and thinking, right, we could take that competency for the development of that, so we are just expanding their role.

As well as that, what we have found is within a small team, it's very much confidence in each other's abilities, everybody has got different strengths and weaknesses, especially when they are starting on that advanced clinical pathway, and as well, when the consultants are making that final decision over whether somebody has to stay at home or whether ... when you are phoning them from a house to say, I have got somebody and this is the situation, if they have not got complete confidence in you and know where your strengths and weaknesses are, then they are going to say, err on the side of caution, admit ... so what we developed was the OSKI examination, and this basically just allows them to supervise you through 3 assessments, so they can see exactly where your strengths and weaknesses are, and it's just the Clinical elements of an examination and then they are able to give you feedback. The practitioner is particularly like that as well because they get really constructive feedback, so it lets them know how they can develop and what bits they need to focus on, and it allows that team to gel and build together.

The next step for us is obviously integration is around the corner, we have had some challenges, as I say, between primary and secondary care. We find it's much easier to work with local authorities than it is between primary and secondary care at times, so it's trying to get people to stop fighting and work together to improve things, and also succession planning, because it's a very unique service, we have had a number of community nurses that we have encouraged to do the competency framework and the training and we have brought them through the team, but actually when we have had posts become available and we have went back to them and said, do you want to come and work with us, they have said, actually, no ... it's too acute, the length of stay is too short for me, I actually prefer working with my palliative care patients, getting a relationship over a long period of time, so it's a different type of care, and that isn't why I came into community nursing. Which you can understand. If you look at hospital care, it's probably the equivalent of working in a ward or working in an A&E department, not everybody would want to work everywhere, so actually a lot of staff that we thought we would be able to recruit in the future are saying, actually, no. So it's how we pick staff and how we develop them as we are going on, and just maintaining the pace of change. We are currently looking at the other 2 hospitals and we are starting to make plans for rollout across the whole of Lanarkshire.


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