Physical and mental health team up to reduce repeat admissions to emergency departments

A programme devised between Oxford University Hospitals NHS Foundation Trust (OUH) and Oxford Health NHS Foundation Trust has helped improve support for people who frequently attend emergency departments at the John Radcliffe and Horton General hospitals.

This group of patients, while consisting of only a small number of individuals, represented almost 10 percent of attendances at emergency departments. The complexity of their health problems often resulted in extended visits to the emergency departments, which led to higher admission rates and an increased number of bed days.

Trust emergency medicine clinicians and the Emergency Department Psychiatric Service provided by Oxford Health NHS Foundation Trust, recognised that these patients' visits to the emergency department were not explained by one presenting complaint, but also range of mental health, psychological or social problems which proved difficult to solve in one visit.

As a result, the Oxford University Hospitals' emergency department clinicians and Oxford Health’s Emergency Department Psychiatric Service increased their collaboration with other healthcare professionals including Oxfordshire's community and inpatient mental health services provided by Oxford Health, specialist consultants, Oxford Community Psychological Medicine Service, the ambulance service, and hospital safeguarding representatives. Together, they formed the Oxfordshire Emergency Department Frequent Attenders Programme.

The Oxfordshire Emergency Department Frequent Attenders Programme

Actions in the programme included closer work with physical health clinics, increased transparency with patients, and improved record-keeping to make sure all health professionals involved with patient care in the emergency department are kept as up-to-date as possible.

The programme improved the teams’ understanding of how people use healthcare services in Oxfordshire.  Improving the use of data meant that clinicians could better identify individual patient’s needs, and work with the wider healthcare community to fill the gaps.  Patients could be referred to specialist services which they may not have been considered for in the past, and this more personalised level of care was made possible by building close relationships with a range of healthcare professionals.

The Frequent Attender Programme has resulted in a marked reduction in the attendance rate for select frequent attenders to the Trust's emergency departments - building up to a 64 percent reduction in monthly attendances for a cohort of patients selected for a Commissioning for Quality and Innovation (CQUIN) project in quarter four of 2017/18, which is well beyond the national target of 20 percent.

Dr Deon Louw, Emergency Department lead for mental health at Oxford University Hospitals, said: "Our collaboration with other health workers has been a vital part of our success in treating people with complex health issues. Our main aim was to provide patients with a more comprehensive level of care, and enable them to access appropriate services. It's improved things for staff, too - by working with colleagues both in the Trust and outside of it, we're able to rely on each other's expertise.

"We've shared our knowledge across the board, and people have been able to give their insights into a patient's health and how best to treat them. For example, we are currently working with our endocrine and acute general medicine departments to develop pathways to support people with diabetes. Sometimes, people will come to emergency departments with a physical problem, but there may be an underlying mental health issue that can exacerbate it.

"We know that emergency departments can be a difficult place for people presenting with a mental health crisis - that's why collaborating with other services, including community organisations and the voluntary sector, is so important. By having a joint approach to treating our patients and developing a targeted and holistic model of care, we've helped reduce the number of people coming back to emergency departments while achieving the best outcome for our patients.

"This means that their needs have been better met, and that we have more time to treat people and look at their longer-term care - for example, we've been able to find local support groups for our patients who would benefit from more community-based help."

Dr Kezia Lange, Consultant Psychiatrist in EDPS, said: "This is an example of great collaboration between the two trusts' clinicians to improve patient care, minimise potential harms caused by over-investigation and inappropriate referrals and to help reduce the pressure on our busy emergency department".

Moving forward

The Frequent Attender Programme has grown in prominence, and the team is regularly approached by doctors, neighbouring emergency departments, and GPs for advice. Longer-term, the team intends to continue working on the programme, and further build a local and regional collaborative network. Their success has been recognised by NHS England, and the team look forward to sharing their knowledge with other NHS trusts.