Background Within England, increasing numbers of frail patients are receiving support from community-based specialist palliative care services (Polak, Hopkins, Barclay, et al. Br J Gen Pract. 70(699), e757-e764). Hospital Palliative Care Team (HPCT) data highlighted that residents were transferred to local Emergency Departments (ED) despite having their care home documented as preferred place of care and death. The hospice’s Frailty Advanced Clinical Practitioner (FACP) started to review collaboration between Primary Care Networks (PCN), Care Home Team (CHT) and hospice, identifying that current systems were working in isolation, with care homes wanting collaborative working between services to advocate for residents in crisis.

Aim To reduce avoidable ED admissions for frail, palliative patients using collaboration in care homes.

Method FACP utilised stakeholders across the Integrated Care Board (ICB) to navigate key groups (Heckert, Forsythe, Carman, et al. Res Involv Engagem. 2020;6:60). A working group with the largest PCN was formed. The CHT did an initial ‘plan, do study, act’ (PDSA) cycle after implementing a personalised care plan (PCP) into forty-three care homes based on their own ideas. PDSA 1 showed no improvement in the number of ED admission rates; therefore, a workshop with stakeholders was held. The Quality Improvement (QI) Lead provided statistical process control charts (NHS England. Statistical process control tool. [internet]) showing ED admission rates and low numbers of PCPs. Fishbone diagrams were used by the group to visualise barriers and ideas for change (National Institute for Health and Care Research. NIHR CRN NENC quality improvement tools. 2022 [internet]).

Results A second PDSA cycle is ongoing after re-designing the PCP using ideas from the workshop. It is being trialled on residents who are at risk of re-admission into ED from five care homes. It is streamlined to the Network Contract Direct Enhanced Service and the CHT meets weekly with the care homes to support the completion of PCP.

Conclusion Using QI methodologies across ICBs resulted in a collaboration between services, with continuing development of documentation and relationships. Further quantitative evaluation is needed once the second PDSA cycle is complete.