Area Case Study: Keeping elderly patients out of hospital

Published: 1st October 2021
South Warwickshire NHS Foundation Trust’s (SWFT) Frailty Service have been leading an array of activities to aid patient referrals. In this article we uncover the key activities across the trust which ultimately work towards keeping patients out of hospital, especially as we head towards winter.
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South Warwickshire NHS Foundation Trust (SWFT) Elderly Care team have been working on a range of projects to keep elderly and frail patients out of hospital. Over the past year, they have successfully introduced new pathways and practices to aid appropriate patient referrals.

In this article, we present the various activities which the SWFT Elderly Care team have been working on, in collaboration with Consultant Connect, over the past year.

Key milestones
  • June 2020: PIFU Respiratory

Just over a year ago, Patient Initiated Follow Up (PIFU) for Respiratory was set up. This is a direct line, allowing patients to call in to the team of consultants.

  • January 2021: The Perfect Week 1

An initiative called the ‘Perfect Week’ launched in January this year. The first Perfect Week aimed to aid patient flow and discharge, as well as facilitate internal communication. This was achieved by setting up internal referral lines to wards at the trust via Consultant Connect. The lines acted as a shortcut for clinicians, and they facilitated internal communication, as they allowed clinicians to bypass the switchboard and avoid long waits. 21 direct lines to wards across the trust were set up during Perfect Week 1.

  • February 2021: PIFU Frailty

In February, a PIFU line for Frailty was set up following the success of the PIFU Respiratory line. Allowing patients to call in, directly to the team of consultants, assists the flow of recently discharged patients at the trust.

  • February 2021: PDSA Frailty 1

Also, in February this year, the first Frailty Plan Do Study Act (PDSA) initiative was activated. This ran for a two-week period with the aim to assess whether the West Midlands Ambulance Service (WMAS) crews were able to access the Elderly Care consultants in a timely way. This PDSA showed that, throughout the 2-week period, calls were answered in just 34 seconds on average, with 75% of calls being answered by the first consultant on the rota.

  • March 2021: The Perfect Week 2

In March the second Perfect Week occurred, and it ended up being extended to a two-week period. Again, this aimed to support patient flow and discharge, as well as facilitate internal communication. However, this time the Perfect Week was promoted internally, with communications shared with clinicians to encourage usage as well as promotions to encourage Consultant Connect App downloads.

  • April 2021: PDSA Frailty 2

The second PDSA for Frailty began in April this year and lasted two months. The SWFT Frailty service provided early specialist intervention for patients that may need conveyance to Emergency Department (ED), in efforts to prevent potential admission and/or attendance to ED.

How this worked in practice…

  • When a paramedic from WMAS was visiting a Frailty patient, who was considered for conveyance, they could call the Strategic Capacity Cell (SCC) via Consultant Connect, to investigate appropriate and alternative pathways available in the area.
  • During a paramedic visit to a Frailty patient that was being considered for conveyance, a call was made via Consultant Connect to the team at SWFT Frailty Service. A clinical triage by a Consultant Geriatrician was conducted and a decision was made to determine the next and best outcome for the patient. These outcomes were captured in Consultant Connect for reporting and learning purposes.
  • The SCC team, who are based in a control room in Brierly Hill, were then contacting the Frailty PDSA team, to make decisions on the patient’s next outcome – for example, ‘Refer to GP’ or ‘Community CP Visit’.
  • The SCC team had access to the Ambulance crews’ electronic patient report form. This helped to access the on-site observations in collaboration with the PDSA team.
  • By the SCC team triaging the call, the referral was passed on, freeing up the on-site paramedic/s.

Performance statistics:

  • 45% of calls resulted in an avoided admission/attendance to the Emergency Department (ED)
  • The other 55% of calls resulted in necessary admission/attendance to ED or transfer to Frailty Assessment Area (FAA), following specialist Advice & Guidance
  • In the two-month period, the Frailty team answered > 200 calls from WMAS
  • May 2021: Patient Connect – Gastroenterology

The latest milestone of SWFT and Consultant Connect working in collaboration is the launch of Patient Connect for Gastroenterology. This service was set up as a direct, secure way for SWFT Gastroenterology consultants to make outward calls to their patients for their annual check-ups. The calls are made via Consultant Connect so no telephone numbers are shared, and all data and recordings are available via the secure Consultant Connect dashboard. The service has allowed 25 patients to receive their specialist check-up, since launch.


Additional activities…

In addition to the host of activities discussed above, the SWFT Elderly Care team answer calls via two direct Advice & Guidance lines – ‘The Frailty Unit’ and ‘Care of the Elderly’ via Consultant Connect. There are various users of these Advice & Guidance lines, including WMAS, community nurses and GPs.

The Frailty consultants also use Consultant Connect to call Advanced Clinical Practitioners (ACPs). This allows for a two-way collaborative conversation, as the consultants can gather more information from the ACPs regarding their patients.

The leadership team at SWFT then use data reports accessed from the Consultant Connect dashboard, to monitor the impact of the various activities and to inform strategic planning.


If you have any questions or would like to find out more, email or call us on 01865 261 467.

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