What was the issue you were addressing or working on?

The objectives of COMPASS include:

  • To improve the identification of older people in the community at risk of escalation / hospital admission
  • To facilitate and provide proactive case management for those at risk of admission by the most appropriate service
  • To prevent the emergency admission of patients to hospital by facilitating and providing timely access to alternatives within domiciliary, outpatient, Day Hospital and inpatient settings
  • To facilitate the discharge and prevent later readmission of patients from hospital following a planned or emergency admission
  • To provide a point of contact for GPs to seek advice/ discussion with a Medicine of the Elderly (MoE) consultant, with the aim of reducing emergency hospital admissions where possible and appropriate
  • To conduct comprehensive assessment for patients in a range of settings
  • To improve understanding of, and communication between primary, secondary and social care services, leading to better outcomes for individual patients/ service users
  • To identify areas for further improvement, collaboration and joint working and to develop a vision for future ways of working, including a ‘virtual ward’ ‘hospital at home’ model

What you did?

MDT meetings are now established in two areas of the city and plans are underway to roll out in the remaining two areas.  A Steering Group has been established to review progress, develop and implement the future vision, which includes developing a hospital at home model.

What were the outcomes - benefits or otherwise?

Significant positive change is being noted amongst participating services.  Pro-active case-finding is becoming an established element of COMPASS, with more integrated care planning for patients who have been identified as at risk of hospital admission or re-admission.  The model is also achieving improved understanding and communication between services from across the system, leading to better outcomes for individual patients/ service users.

Within the original South-East locality, a full evaluation report is being compiled. Initial data includes:

  • the rate of unplanned admissions to hospital within South East Edinburgh is reducing, whilst planned admissions are increasing (detailed analysis follow in full HIU evaluation)
  • MDT discussion of patients: over 1,000 patients have been in connection with COMPASS in the South East since April 2012
  • Liberton Day Hospital activity has increased from approx 7 urgent referrals per month (prior to April 2012) to 13 per month (April 2012 – February 2013).
  • IMPACT received 54 referrals from COMPASS (South East) between April – December 2012, 41 of which were deemed suitable for the service. Of these 31 were accepted into IMPACT for ongoing management of their Long Term Condition and 10 were referred to other appropriate services. During this time 5 people were admitted to hospital where they subsequently died.
  • GP feedback about the single point of contact has been very positive. Feedback from a recent survey which had a total of 24 respondents suggested that:
    • 89% found access to a Hospital Consultant Geriatrician by mobile phone to be useful or very useful
    • 79% felt that the COMPASS service had led to a change in their clinical practice in the management of at-risk frail elderly patients
  • 50% of referrals made by GPs to COMPASS have been suitable for an urgent day hospital assessment. Other alternatives pathways have included direct admission to MoE beds (not through A&E), domiciliary visits, signposting’ round a complex community services and peer support in the assessment of the frail elderly.

Contacts - to find out more

Caroline Clark,   0131 469 3220