Acute admission to hospital is not always an appropriate environment for nursing home residents who may be able to receive care in the comfort of their home; often a preferred option for both residents and their families. With the current restraints on provision of services and limited capacity and hospital beds, long delays in emergency departments impair comfort and dignity, whilst also causing delays in treatment. In addition it leads to more overwhelm for the already busy emergency departments and adds pressure for on Welsh Ambulance Services NHS Trust (WAST).
A team at Cwm Taf Morgannwg University Health Board created the Clinical Navigation Hub to help reduce this problem. Healthcare workers can call them for advice on how to manage cases as an alternative to calling 999 and find out if they can avoid visiting the emergency department and deliver more suitable care, appropriate for each situation.
The foundations were set for the Clinical Navigation Hub in 2020 during some initiatives that were deployed during the Covid pandemic. This work was revisited and built on, and then accelerated in 2023, when a suite of services and clinical pathways were developed, which now constitute the Clinical Navigation Hub. The project also became part of the Safe Care Collaborative, meaning the team members had access to support from Improvement Cymru and the Institute for Healthcare Improvement (IHI), in addition to support from the local team at improvement Cwm Taf Morgannwg University Health Board. They attend regular learning sessions to share their experiences and learn from colleagues from across NHS Wales working on improvement projects.
They set a target to increase the delivery of alternative care and reduce inappropriate conveyance to acute hospitals from 0 to 500 by December 2023.
The project involved making sure they had appropriate communication systems for Clinical Navigation Hub service users and that the call receivers were appropriately trained to triage and signpost the calls. They also had to ensure that there were adequately resourced alternatives to acute admissions, for example, ability to provide remote prescriptions, directory for alternative providers, clinicians to visit and pharmacy provision. They have been using Consultant Connect which enables the Navigation Hub clinicians to discuss patients with the consultants in secondary care – ensuring appropriate management plans are implemented at home.
They needed to make the WAST frontline staff aware of the service so that they can call the Clinical Navigation Hub to find out if they are suitable for alternative management. They created a PDSA ramp for their communication strategy which helped them find improved ways to communicate with them, for example by leaving leaflets with the contact number of the seats in the ambulance for easy reference, and a message on the paramedic screen at the start of the shift.
South Wales Police also called them, instead of an ambulance, when they needed assistance with verification of death. If there was a sudden death which the police deemed non-suspicious, they called the Clinical Navigation Hub, which previously would have required an ambulance response.
Some of the success stories included an elderly patient with COPD who called 999 with worsening breathlessness, who was visited at home and safely treated with oral antibiotics for a chest infection. Another person called 999 after a fall during transfer to a chair, they were reviewed safely at home and given a referral to appropriate care which didn’t need to involve an ambulance.
During 2023, the Clinical Navigation Hub dealt with over 5000 cases. Of these, more than half of the cases came directly from care homes or WAST. There were 1133 successful interventions from care homes recorded – these were when care homes called the Navigation Hub directly instead of an ambulance – and resulted in an 88% conveyance avoidance rate. Also recorded were 1414 referrals from WAST with a conveyance avoidance rate of 78.9%.
Staff say that it has meant a lot to them that they are helping make sure patients have care in their destination of choice, and that this helps them meet the needs of the patients. The team feel particularly proud of what they have delivered in such a short timescale, achieving much more than their original target.
Andrea Dorrington, Lead Nurse for Urgent Primary Care at Cwm Taf Morgannwg University Health Board said, “The Navigation Hub has a team of clinicians who are assessing and treating patients in the community or in their own home. This home first approach promotes personalised care, enhances patient comfort and reduces unnecessary hospitalisation. This, in turn, helps to foster a more supportive environment for patients to recover.
“Working alongside colleagues from the Welsh Ambulance Service, the Navigation Hub, through its partnership work, has been able to help release valuable 999 ambulance capacity so more patients are able to receive a timely response. This community based approach to delivery of timely and responsive healthcare is also helping to reduce costs and improve patient outcomes and satisfaction.”
Dominique Bird, Deputy Director of Improvement Cymru said, “The Clinical Navigation Hub has created a transformative impact on patient outcomes. The success stories and conveyance avoidance rates demonstrate the power of their innovative solutions, we are keen to use the learning from the great work of this team to help similar initiatives across Wales.”
Moving forward the plan is to spread the work across the health board and Improvement Cymru are keen to support the team to work with similar teams in other health boards across Wales.
If you are interested in finding out more please contact Luke Morton, improvement lead at Improvement Cymru, and ambulatory workstream lead for the Safe Care Collaborative, by emailing Luke.Morton2@wales.nhs.uk.