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Full details of the ACAT programme may be downloaded here. Contact details for Prof Bhowmick are on the cover of the book.

Torfaen is a burrough of Gwent, South Wales. A community based programme for older people, offering assessment, diagnostics and treatment in the patient’s home on the day of referral, recently won the national 2008 BUPA Foundation Care Award.

Bupa’s group medical director and vice-chairman of the Bupa Foundation, Dr Andrew Vallance-Owen said: “This service has reduced the gap between primary and secondary care through close collaboration with GPs, social services and the hospital trust. It is an excellent example of an innovative redistribution of resources to modernise and improve the existing service.”

Prof Bim Bhowmick, clinical director of Torfaen Intermediate Care Services, said: “We wanted to provide our older population with real choice about who, where and when they can receive effective care. We know that older people living in our borough don’t want to go to hospital for treatment unless it’s absoutely necessary, but we are also aware that these are the very people who can fall between the gaps of traditional care provision. The Bupa Foundation win means a tremendous boost to the team as we continue to meet the needs of this vulnerable group and reduce the immense burden on NHS beds as a result of unnecessary admissions.”

In his very detailed submission to BUPA, entitled: “Torfaen Advanced Clinical Assessment Team (ACAT) : Promoting patient choice and preventing unnecessary hospital admissions”, Prof Bhowmick sets out how the programme works - from team member roles to referral systems, planning and management, the virtual ward, trend analysis and communication strategy.

The aims of the progamme were to provide seamless care; to develop the concept of a team “without walls”, with free flow of information; to provide prompt identification and response to older people’s health and social care needs, helping to avoid crisis management and unnecessary hospital or care home admissions; and to alleviate pressures on acute care services, reduce delayed discharge and institutional care home placements.

In what he refers to as his “going going gone syndrome”, Prof Bhowmick says: Very often, frail people prefer not to go to hospital for treatment; however in the current provider climate they have little choice. Loss of dignity, loss of independence and premature institutionalisation are often the result of inappropriate emergency medical admissions.

What is convenient to the health provider - transferring patients to an acute facility for safety and assessment, is often not convenient for the patient. Long waiting times, disorientation, the fear of nosocomial infection, breakdown in familial and social support systems and the potential to fall, are some of the concerns voiced by many individuals. The patient may aslo wait considerable lengths of time for senior clinical input and diagnostic testing, be admitted “to be safe”. It places enormous stress on family, carers and friends as well as increasing both the physical and mental health risks associated with hospitalisation of older people.

The cornerstone of the programme, Prof Bhowmick told me, is to get the general practitioners on board. As outlined in his communication strategy, the consultant physician in intermediate care visited all thirteen general practices in the county, and encountered some scepticism in the early stages of setting up the programme. Also approached were district nursing teams, palliative care teams, the Welsh ambulance NHS trust, hospital discharge liaison nurses, acute medical admission unit teams, to name but a few entities subjected to the geriatrician’s doorstepping campaign.

The Team also introduced the “virtual ward round”. This is undertaken by the consultant, twice a week and all patients receiving assessments are discussed and management plans agreed. Medical and non-medical interventions are communicated to the patient’s general practitioner, confirmed by fax. The patients and their families are kept apprised by telephone.

Training
SpR trainees in geriatric medicine in South Wales now spend six to eight months working within this service model for intermediate care. GPs are also sending their registrars, medical students and their practice nurses to observe the team in action.

Outcome
In the first year of the service (Jan 2007 to April 2008), 1,208 patients were referred to ACAT - an average monthly referral rate of 75.5 patients.

There was a total 2,729 visits including the preliminary clinical assessment, diagnostic visits, follow up visits and hot clinic appointments. The age range of patients seen is 49 -100 years with approximately 10 to 15% of the referrals being under 75 years. Referrals from care homes via a GP accounted for approximately 25% of the total community referrals. The number of hospital admissions prevented during this period were 975 i.e. 80.71% of referrals. The hospital admissions from care homes have practically ceased during the daytime.

Financial implications
The potential saving, based on a conservative cost of £226 per bed day in a district is an estimated £200,240 attributable for the admissions prevented between January 2007 to April 2008. The average length of stay in Royal Gwent Hospital (DGH) for an older patient ranges from 10 to 12 days. Using the same formula, this amounts to a potential benefit of between £2 million to £2.6 million, and represents significant cost savings to all funding organisations.

Article based on information from Torfaen Advanced Clinical Assessment Team (ACAT) : Promoting patient choice and preventing unnecessary hospital admissions

BGS Newsletter, Dec 2008
Issue 19 ISSN 1748-6343 19