P-198 Reducing avoidable readmissions for people with complex needs associated with frailty

Abstract

Older people are the most frequent users of services and when admitted to hospitals are at greater risk of complications leading to longer lengths of stay and readmission rates. The current design of secondary care services fail to identify the complex underlying needs of older people associated with frailty, including palliative care needs. This results in poor discharge planning and subsequent avoidable future admissions. However, for those people who are admitted to community palliative care services their risk of a readmission to hospital within 28 days is halved. This presentation aims to share the findings of a service transformation project implemented by the author as part of their MSc dissertation. This was achieved with the application of an Experienced Based Design approach with other stakeholders, along with the principles of Six Sigma to understand the root cause, and was supported by a systematic review of the literature. Which informed the case for the role of an Anticipatory Care Nurse based in A and E of an acute trust to educate front door clinicians how to identify people in their last year of life and develop person centred care planning. An action research and rapid appraisal technique was applied through the use of the PDSA cycle was implemented to evaluate the service transformation project. A 45% increase in the number of referrals to the Specialist Palliative Care Team and subsequent increase in referrals to community palliative care services was demonstrated. This was achieved by improved identification of need by front-line clinicians, resulting in widening access to hospice and palliative and end of life care and subsequent person- centred care planning and well-being. Thus, offering a solution to the STP aspiration to reduce avoidable admissions to hospital by 30%. Lincoln University are keen to support further research through expansion of this project.