* This website is a Q-Exchange report. Coloured boxes indicate information of general interest.
opportunities not to be missed!
Throughout the country teams are developing High Intensity User (HIU) programmes. Many start off with the agenda to reduce ED use. What we would say is this: don't lose focus of the patient and how you can care better for individuals. This is one of the essential building blocks of a best-practic model - see our project journey page.
But there's more. There are opportunities that go beyond the obvious. So before we talk about the lessons of our QI journey, we want to take this chance and give some insights into the massive potential of a quality HIU service. For those who don't have the time to read the multiple documents we have produced, here is an excerpt from our background summary. The complete document with references are available in the resources section.
But there's more. There are opportunities that go beyond the obvious. So before we talk about the lessons of our QI journey, we want to take this chance and give some insights into the massive potential of a quality HIU service. For those who don't have the time to read the multiple documents we have produced, here is an excerpt from our background summary. The complete document with references are available in the resources section.
Opportunities for achieving wider healthcare impacts:
Recognising the unmet needs prevalent in the HIU population allows healthcare providers to identify gaps in community-based services. For example, people with chronic pain may be utilising unscheduled care due to a lack of psychological support available in scheduled care, i.e. outpatient clinic-based settings. HIU programmes can change the focus from diverting apparent inappropriate healthcare-seeking behaviour, to creating awareness of the system failures that result in these patterns. HIUs effectively become the canaries in the coalmine, enabling clinicians to recognise a potential mismatch of what services are needed and what is available. Jacob et al suggested that EDs are ideally placed to identify somatoform symptoms in HIUs, but this will only be valuable if and when adequate alternative pathways to care are developed. Ultimately, clinicians across the spectrum will be empowered when approaching commissioners with accurate data on resource requirements.
There is massive potential in HIU services to enhance the impact of other programmes that rely on the accurate identification of at-risk individuals. An example in Oxfordshire is the Integrated Respiratory Team, a multidisciplinary approach aimed at supporting COPD and asthma patients to achieve better self-care and access to community-based support. Working in parallel with such projects allows for a more effective use of resources by identifying patients who use unscheduled services excessively, and aligning efforts to reach similar goals. And while cost-reduction may not be a priority when the aim is meeting patient-defined goals, due to epidemiological overlaps and shared aims with e.g. substance abuse programmes, positive financial results over the wider health economy is possible in a whole system approach that has, at least in part, a focus on preventative medicine.
The potential of HIU programmes to recognise vulnerable individuals goes beyond data sharing on the attendance rates of patients with known long-term conditions, e.g. the example of COPD above. As mentioned before, many HIUs with physical complaints (including complaints with no demonstrable organic cause) have underlying and often undiagnosed psychological needs. Nevertheless, research has shown that ED physicians regularly fail to identify comorbid mental health problems among both frequent users and other patients. While screening for anxiety and depression in the overall ED population may not be feasible or appropriate in the acute care environment, HIU services provide an opportunity to include screening in this high-risk group. Consequently, patients will be able to get the treatment they need.
In addition to providing basic care for undiagnosed conditions, positively identifying common mental health problems among HIUs has the same value as recognising stroke risk in patients with irregular heart rhythms. In other words, healthcare providers will be able to prevent life-changing and possibly fatal events. In this patient group the most serious of such events is suicide, still a major cause of death in the UK*. Evidence shows an increased likelihood of utilising healthcare in suicide cases when compared with control groups. Additionally, according to a study by Kvaran et al “number of visits to the ED is an independent risk factor for suicide adjusted for other known and important risk factors”, including age, gender and psychiatric diagnoses.
* According to Public Health England, in 2016 suicide was the leading cause of death in males and females aged 10 to 34 years, and in males aged 35 to 49 years.
Recognising the unmet needs prevalent in the HIU population allows healthcare providers to identify gaps in community-based services. For example, people with chronic pain may be utilising unscheduled care due to a lack of psychological support available in scheduled care, i.e. outpatient clinic-based settings. HIU programmes can change the focus from diverting apparent inappropriate healthcare-seeking behaviour, to creating awareness of the system failures that result in these patterns. HIUs effectively become the canaries in the coalmine, enabling clinicians to recognise a potential mismatch of what services are needed and what is available. Jacob et al suggested that EDs are ideally placed to identify somatoform symptoms in HIUs, but this will only be valuable if and when adequate alternative pathways to care are developed. Ultimately, clinicians across the spectrum will be empowered when approaching commissioners with accurate data on resource requirements.
There is massive potential in HIU services to enhance the impact of other programmes that rely on the accurate identification of at-risk individuals. An example in Oxfordshire is the Integrated Respiratory Team, a multidisciplinary approach aimed at supporting COPD and asthma patients to achieve better self-care and access to community-based support. Working in parallel with such projects allows for a more effective use of resources by identifying patients who use unscheduled services excessively, and aligning efforts to reach similar goals. And while cost-reduction may not be a priority when the aim is meeting patient-defined goals, due to epidemiological overlaps and shared aims with e.g. substance abuse programmes, positive financial results over the wider health economy is possible in a whole system approach that has, at least in part, a focus on preventative medicine.
The potential of HIU programmes to recognise vulnerable individuals goes beyond data sharing on the attendance rates of patients with known long-term conditions, e.g. the example of COPD above. As mentioned before, many HIUs with physical complaints (including complaints with no demonstrable organic cause) have underlying and often undiagnosed psychological needs. Nevertheless, research has shown that ED physicians regularly fail to identify comorbid mental health problems among both frequent users and other patients. While screening for anxiety and depression in the overall ED population may not be feasible or appropriate in the acute care environment, HIU services provide an opportunity to include screening in this high-risk group. Consequently, patients will be able to get the treatment they need.
In addition to providing basic care for undiagnosed conditions, positively identifying common mental health problems among HIUs has the same value as recognising stroke risk in patients with irregular heart rhythms. In other words, healthcare providers will be able to prevent life-changing and possibly fatal events. In this patient group the most serious of such events is suicide, still a major cause of death in the UK*. Evidence shows an increased likelihood of utilising healthcare in suicide cases when compared with control groups. Additionally, according to a study by Kvaran et al “number of visits to the ED is an independent risk factor for suicide adjusted for other known and important risk factors”, including age, gender and psychiatric diagnoses.
* According to Public Health England, in 2016 suicide was the leading cause of death in males and females aged 10 to 34 years, and in males aged 35 to 49 years.
and now for more project-orientated lessons.....
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EnablersBy far our most valuable asset was the contribution made by service users. Thank you to all of you - you know who you are! Not only did you steal the limelight at our conference (unsurprisingly), but you inspired and informed us along the way. In fact, we are convinced that every QI project and NHS service should put patients at the centre of their design process.
But of course we also have to acknowledge the value of our networks, both existing ones and new ones. These networks gave us access to the many individuals we hoped to engage with. Like-minded colleagues within the Q-Community further empowered us. |
obstaclesWe knew we would have to coordinate many individual groups across a large area. What we didn't count on was the resource challenges each group would face in their respective situations. This was exacerbated when the CQUIN on frequent attenders came to an end. As a result the idea of forming a steering group and implementing PDSA cycles were brought to a halt.
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lessons for future projects
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For us:
With the strict deadline of designing our project in time for the Q-Exchange bid and event, we were not able to accurately anticipate how much other teams would be affected by resource-limitations, which of course impacted on their capacity to participate in service improvements. A lesson that we have had to learn the hard way. But the real lesson was not to be beaten and to keep our chins up. We had to be flexible and find another way of meeting our goals and facilitate the design of improved HIU services. In other words, you may have to change your methods, but you don't have to compromise on your vision. |
For everyone:
Designing and developing quality healthcare is not a 12 month undertaking. More often than not you have to think of it in phases. And as long as you work hard, you (and others) will have strong foundations to build on and benefit from. |
For others:
Communication, communication, communication! Talk to others, phone, email...write a telegram if you have to. A HIU project is a big stage production. And if you are going to put on a show with a large number of actors on the stage, you have to make sure everyone reads the script. Good communication also helps to avoid reinventing the wheel. One of the biggest risks for us was the unavoidable issue of information governance. But the anxieties of IG were reduced when we learnt about an evolving project specifically designed to improve health and care by connecting and sharing information. We contacted the project leads and discussed our shared goals, thereby putting the priorities of HIU services on their agenda of case uses. |
