THE LATEST EDITION

November 2018
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Right Place, Right Care, Right Time

In July 2008 the government published the final report of Lord Darzi’s Next Stage Review, High Quality Healthcare for All, which spelt out a long term vision of an NHS that is high quality, personalised and clinically led. With public finances now under pressure, the Department of Health’s clear policy position is that high quality, safe care is cost effective and can deliver efficiency savings. It is therefore vital that the NHS ensures that patients are in the right place to receive the care they need at the time they need it.

The NHS in Rotherham is keen to address this issue of appropriateness of care and resource utilisation. The health and social care community recognised that patients may remain on acute care wards inappropriately for many reasons, including a lack of intermediate care facilities. They wanted to address this systematically in a patient-focused way that would also support commissioning new services to fill any gaps. At the same time, McKesson was looking to adapt its well-used and highly respected InterQual® tool for the NHS.

Rotherham Health and Social Care Partnership

Rotherham is in the lucky position of having a very straight forward health and social care economy. There is one acute provider, Rotherham Foundation Trust, one community services provider, Rotherham Community Health Services, and one PCT that is coterminous with the local authority which also provides social services. There is close co-operation between all four and in 2009 they formed a Health and Social Care Partnership and began the project with McKesson to adapt and test InterQual.

Choosing McKesson

McKesson UK, healthcare IT solutions and services specialist, formally launched InterQual in the UK in October 2008. InterQual is a computerised tool used to assess whether patients are in the appropriate care setting for their individual needs. It is already used in over 5,000 healthcare settings worldwide, where it is used primarily to support decisions about patient care in insurance-based healthcare systems. However, McKesson felt it had wider application and could be adapted in the NHS to support commissioners and providers with effective utilisation management and appropriateness of care validation.

InterQual has at its heart a rich repository of clinical evidence, developed over 30 years. Over one third of the 16,000 citations are derived outside the USA. McKesson’s highly trained clinical development team continually assess the evidence with feedback from an InterQual Clinical Panel of 800 experts. As a result, all InterQual criteria have a level of credibility and integrity that cannot be found anywhere else.

The power of InterQual lies in applying this evidence-base in a systematic way to individual patients. When aggregated, the results of individual assessments and clinicians comments on them provide commissioners and managers with a rich source of evidence about bottlenecks and service gaps. This can be extremely powerful as a source of evidence for service redesign.

Rotherham Partnership had been involved with McKesson since 2004 in a project to redesign unscheduled care. Since then McKesson has maintained a close relationship with the Partnership, culminating in the implementation of an NHS-specific version of InterQual in 2009.

The project

Rotherham Partnership began implementing InterQual in February 2009 initially on three wards covering emergency admissions; trauma and orthopaedics; and healthcare for older people. It was also implemented in the community in a purpose built facility for people with chronic obstructive pulmonary disease. In each care environment a case manager – a senior nurse or therapist – was appointed and trained to use InterQual. These Case Managers assessed patients both on admission and throughout their hospital stay and where they identified that patients could be cared for more appropriately elsewhere, they worked to facilitate a supported discharge.

All patients are reviewed against InterQual’s admission criteria and then against the continued stay criteria while they are on a ward using the system. In the first 16 weeks (16 February 09 to 8 June 09), 3631 reviews were undertaken on 892 patients. Of those reviewed against the acute criteria, 558 were admission reviews, 2872 were against the continued stay criteria and 83 reviews were undertaken against discharge screens.
The hospital found that 49% of the admission reviews met the criteria for an acute admission; 45% did not meet the criteria. The remaining reviews were either redirected off the project or referred for a secondary review.

The continued stay reviews show that 15% met the acute criteria and 77% did not meet. Again, the remaining reviews were either redirected off the project due to transfer to other wards or were sent for secondary review.

This data shows that the 77% of continued stay reviews and the 45% of admission reviews which did not meet the criteria resulted in patients occupying an acute bed, for a total of 1574 variance days, when patients could have been cared for at a sub-acute level if that level of care had been available in Rotherham.

InterQual has subsequently been rolled out across respiratory medicine, and plans are in place to use the criteria in a modified way on the Stroke Unit and obstetrics and gynaecology in order to undertake retrospective audits. A further two Case Managers have been appointed at the acute trust in order to roll out to unscheduled care.

In the medium term, the Partnership hopes that InterQual will support the World Class Commissioning agenda by providing data for commissioners, inform Transforming Community Services and provide data about variations on length of stay.
Realising the benefits

It is early days for this project but already the Partnership perceives a range of benefits.
Defining the problem

On one level, the project has helped managers confirm and quantify what they already knew. Rotherham Foundation Trust’s Chief of Quality & Standards/Chief Nurse Jackie Bird says: Our priority is to get care and clinical services right for the people of Rotherham. The problem for the Trust was that we were not getting the flow of patients out of the hospital right. We did not believe that we had the right level of care outside the hospital in the community.

Kath Henderson, Chief Nurse and Managing Director of Rotherham Community Health Services, agrees: My feeling is that we have the care but not the right levels. We have no community hospital, for example. The skills are there but there are not enough of them. We are now getting evidence about the level of underlying need that supports our gut feeling.

Project Lead at the acute trust Carole Lavelle adds: InterQual is clearly defining a group of patients with sub-acute care needs. Our feeling that we need a resource for these patients with the appropriate skill mix is being proved correct.

Increasing clinical engagement and developing new roles

A major success of the project has been engaging clinicians. InterQual is a clinical tool that requires a high level of knowledge and expertise. Gaining clinical engagement including support from consultants has had benefits.

Lavelle says: Clinicians have the same frustrations as managers in terms of moving patients on. Once they were reassured that InterQual did not replace their clinical judgement and that this was more than simple admission/discharge criteria, they were happy.

The creation of new Case Manager roles has allowed the trust to develop some of its most talented band seven nurses and therapists.

Improving patient care

Case Managers report numerous examples where experience told them that a patient needed moving to a less acute environment but InterQual provided the evidence-based assessment to confirm this.

Case Manager Michelle Morgan recalls how she was able to facilitate a care package for a patient who required antibiotic therapy at home. She says: The assumption was that the rapid response team could not provide the service when in fact they could. InterQual was the trigger for making this happen. We are using it to change people’s mindsets.

Conclusion

The project in Rotherham is now demonstrating that InterQual is adaptable for the NHS and can deliver not only significant benefits for patients but also relevant information for commissioners and potentially significant cost efficiencies.

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