FYLDECOAST FREQUENT CALLER PILOT

Three Month Interim Report

Service / Frequent Callers of 999
Commissioning Groups / Blackpool and Fylde & Wyre CCGs
Project Lead / Rhian Monteith, Clinical Lead for 999 Frequent Callers
Secondment Period / August 2013 – January 2014
1. Purpose
1.1 Aims
In August 2013, Blackpool and Fylde & Wyre CCGs jointly commissioned a six month pilot to :
  • Effectively manage frequent callers of North West Ambulance Service within the FyldeCoast footprint.
  • Establish and utilise multi-agency and existing professional services to negotiate an adequate reduction in 999 calls.
  • Demonstrate a reduced workload on unscheduled care services and the wider health economy resulting from reduced 999 calls, which otherwise would have attended the Emergency Department or result in a ward admission.
  • Design and test a robust and sustainable approach to safely manage the chaotic and demanding nature of the patient group.
  • To provide fertile commissioning intelligence and in doing so, lower the stigma associated with frequent callers.
Within three months, all of the above aims have been met and exceeded expectations.
1.2 Evidence Base
One of the areas of increasing activity and cost in relation to unscheduled care services is emergency ambulance call outs, with activity growing at approximately 6% per year. The project lead, using data from North West Ambulance Service (NWAS), identified through a range of routes that there are a significant number of patients who continually call 999 requesting an emergency response. Some have little clinical reason for doing so; others have genuine reason for calling or may be highlighted as vulnerable.
From August to November 2013, the project lead managed the top 50 most frequent, chaotic and vulnerable callers of 999 across the FyldeCoast. This paper focuses upon the 36 with whom the lead has been engaged the longest with and as such, is able to evaluate.
1.3 Objectives
The project has been successful in:
  • Identifying those at greatest risk of 999 calls and Emergency Department attendance.
  • Proactively managing their care using a truly personalised approach.
  • Empowering patients to take ownership of their health and well-being whilst decreasing their dependency upon unscheduled care services.
  • Forming robust community health, social care and mental health contacts to manage patients, creating true integrated working.
  • Providing a service driven by quality with positive human outcomes observed.
  • By acting as a conduit to negotiate and de-escalate issues before a crisis occurs; a situation which has historically lead to a destabilisation of their condition and resulting 999 call.
  • Improving communication and partnership working between those involved in patient care 24/7.

2. Scope
2.1 Service Description
The focus for the work has included homeless persons, self harmers and medical/social presentations, who were not accessing scheduled services and, therefore, rely heavily on unscheduled services for their health care.
Each individual was contacted by phone and assessed using a personalised approach to uncover the ‘real’ reason for calling 999. This revealed a range of presenting complaints; many social issues combined with alcohol dependency, mental health, criminal justice and some extremely complex medical presentations. The vast majority involved addressing a combination of a range of factors in order to reach the desired end. This required the lead to be available by telephone, including unsocial hours, in order for patients to have the one-to-one, personalised approach of de-escalating each crisis before it resulted in a 999 call. The patient group generally have issues around trust so prefer to work with a designated person to begin with before being referred to mainstream services. Even once referred, the lead maintains connected with the patient to act as a central and familiar point of contact so to pull services in the same direction and increasing chances of sustainability. Each patient has a bespoke exit strategy to reduce the dependency on the project lead in order to increase capacity to take on the next cohort of eligible patients.
Following the initial telephone consultation, a process of support ensues with concordance underpinning changes in behaviour rather than compliance through fear of isolation from supportive services or fear of legal restrictions. The lead acts as an advocate for each patient, guiding them through the complex journey and multi faceted approach which has resulted in appropriate use of unscheduled care. Whether the reason for calling is clinical, social, mental health, addiction, loneliness or a combination of any of these factors, the project lead is able to identify and adapt the support to meet the need.
2.2 Whole System Relationships
The project lead has interconnected Health and Social Care through establishing robust working relationships with:
  • Blackpool and Fylde & Wyre CCGs
  • Emergency Departments
  • GP Practice and the wider primary care team Mental Health Services
  • Drug and Alcohol Services
  • Police
  • Social Services
  • Help Direct
  • Hospital Link Officer
  • Housing
  • Blackpool Fulfilling Lives Programme, sponsored by Big Lottery
The services activated depended upon the needs of the patient. The majority have required a combination of the above to align in order to sustain the positive behaviours demonstrated.
3. Evaluation

3.1 Case Studies

Jack

44 year old who lost his wife and children five years ago. At the time he held down a job, had a family, friends and lived in a lovely home. When his family were taken he began drinking every day, slumped into debt and found himself isolated in a bedsit, no friends, clothes, food or job. He calls 999 up to fifteen times a month following potent overdoses, anxiety and lonliness. Jack has criminal justice issues and the police must attend each ambulance call due to extreme violence when intoxicated.

Jack has been a pleasure to work with. He has called 999 only once in the past three months when he received bad news. He is in full time employment and is doing extremely well. He is able to self manage his alcohol intake, has a friends base and is accessing services and appointments by his own volition. The next step is to consider removing the warning flag on his address if his stability continues. He and I are excited about this prospect! In the meantime we are concentrating on resolving day to day issues.

Lucy

56 year old lady living an affluent lifestyle and enjoyed social drinking with friends. Lucy’s husband took ill leaving her to manage the home, finances and self without his support. Increased anxiety developed into alcohol dependency and by the time her husband recovered, she had developed addiction, agoraphobia and social isolation. She called an emergency ambulance 12 times per month with suicidal ideologies and injury caused by intoxication. She was permanently doubly incontinent through intoxication which understandably lowered self esteem, perpetuationg the situation.

Working with Lucy daily for five weeks has helped her to become alcohol free for the past three months; has rebuild her confidence, demonstrated by the re-emergence of weekly lunches out with the girls (alcohol free).

David

David was the most vulnerable patient the project lead had met in fourteen years of working as a paramedic. He was beaten unconscious by members of the public each week and was permanently intoxicated and incapacitated. Living homeless for five years and not engaging in services kept David in and out of hospital up to six times per week and multiple admissions including time spent in intensive care. Eight previous alcohol detoxes failed to be successful.

A multi disciplinary team meeting combining all parties involved in his care contributed to David now three months sober, has a partner, attending all appointments, engaging with services and has a permanent residence.

3.2 Cost

Each patient is assigned a ‘cost’ at the point of contact. This is very accurately based upon the individual’s previous three month’s unscheduled care contacts; specifically 999, treatment in the Emergency Department, mental health liaison assessments, medical admissions and mental health admissions. The costing is then repeated for the three months post intervention and the difference for each of the 36 patients collated to produce the figures below.

In three months, the project has demonstrated a saving of:

  • 433 Ambulance calls (477 calls reduced to 44 calls)
  • 346 Emergency Department attendances
  • 64 Mental Health Liaison assessments
  • 104 Medical Admission days at Blackpool Victoria Hospital
  • 28 days in Parkwood

Total Cost Saving to the Blackpool and Fylde & Wyre CCG - £301,000

Conservative annual projection of £1.2milion

The savings may be realised depending upon the nature of the contracts involved with each provider. The opportunity costs for this project provide fertile commissioning intelligence for 2014/15.

In conclusion, the first three months of the frequent caller pilot has demonstrated effectiveness in personalising patient care, connecting services resulting in positive human outcomes and a significant reduction in unscheduled care contacts.

The frequent caller pilot ends in January 2014, when a full evaluation paper will be submitted for review and ideas will be presented to industrialise the programme within the Fylde Coast footprint.

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