Posted on January 19, 2022

The SHarED (Supporting High impact users in Emergency Departments) project aimed to improve outcomes for the most frequent users of Emergency Departments (EDs). High impact users (HIU) of EDs suffer some of the most severe health inequalities in the UK. There is also a significant financial impact on the NHS with some HIU costing £30,000 per year in ED attendance and hospital admission alone.

Through a collaborative case management approach, significant improvements have been recorded through project SHarED for both EDs and patients.

These include:

  • Improved patient experience
  • A 44% reduction in the number of attendances following the first month of engagement for 89% of the patients engaged
  • Improved staff experiences as measured through a series of staff surveys
  • Collaborative working between multi-disciplinary teams.

The project was proposed by Dr Rebecca Thorpe and the team at University Hospitals Bristol as part of the West of England AHSN’s Evidence into Practice Challenge 2019. The model had been running successfully there for five years before being adopted and spread by the West of England AHSN throughout the region.

“Taking part in SHarED allowed our HIU Team the time, support and resource to really address the underlying issues which can drive patient requirement for large amounts of unscheduled care. By developing Personal Support Plans, in collaboration with patients and other professionals, we managed to reduce attendance rates, reduce admission rates to hospital and smooth the path of patients when they did attend the Department, thereby supporting our staff in dealing with these patients who often have complex health needs. Feedback from our ED staff was extremely positive. Looking to the future, with thanks to SHarED, we’re continuing to develop our HIU service.”

Dr Sarah Harper, Pain Consultant and HIU Team Lead, Gloucestershire Hospitals NHS Foundation Trust

Watch our SHarED project video. 

The challenge

HIU of EDs suffer some of the most severe health inequalities in the UK. HIU and ‘super-users’ are defined as those who attend the ED more than five and 20 times respectively each year. As a patient group, HIUs experience exceptionally high rates of mental health challenges; learning disability; homelessness; substance misuse; domestic abuse and safeguarding concerns. HIUs often attend the ED as they have nowhere else to go.

As well as the negative outcomes for HIUs attending ED when that service may be unsuitable for their needs, and the resulting strain on ED staff to manage high levels of repeat attendances, there is also a significant financial impact on the NHS. Some ‘super-users’ cost £30,000 per year in ED attendance and hospital admission.

Our approach

In 2019, Dr Rebecca Thorpe of University Hospitals Bristol put forward SHarED for The West of England AHSN’s Evidence into Practice Challenge; an open call to healthcare professionals in the region with an evidence-based idea for an initiative or project that would improve healthcare. The initiative has been running at Dr Thorpe’s hospital for five years and had achieved great success in reducing attendances to the ED, as well as supporting users to seek healthcare and support in a more appropriate way. It was one of two programmes selected for adoption and spread across the West of England.

The West of England AHSN worked collaboratively to spread SHarED to all five EDs in the region. The West of England AHSN also developed a thorough SHarED Implementation Guide, run and managed ED staff surveys and created communications including videos .

All teams from across the region joined a monthly call to share progress, challenges and to discuss clinical case studies. They have since been supported in developing their business cases for ongoing service funding.

The HIU teams’ triage and prioritise patients based on multiple factors, including the number of attendances in the last 3 months, the impact on the department when they attend and a number of social factors. Once prioritised, patients are contacted and asked to contribute to a Personal Support Plan written by the HIU co-ordinator and the Multidisciplinary Team. The Personal Support Plan is then used by members of staff in the Emergency Department to provide a consistent approach to assessment and management. Additionally, the Multidisciplinary Team also seek to address any underlying issues through a holistic approach.

“The SHarED project has propelled our work to support some of the most vulnerable, marginalised patient groups in society, who access Emergency Departments frequently, for a variety of reasons. Working with teams from EDs all over the West of England, we’ve educated staff and supported patients to work towards safer patient care and an improved experience for patients and staff. It’s a fantastic example of cultural change across the whole patch.”

 Dr Rebecca Thorpe, Clinical Lead for SHarED and ED Consultant, University Hospitals Bristol NHS Foundation Trust

Impacts to date

Throughout the funded period of the project, the ED teams have delivered training to more than 360 members of staff to raise awareness of the service and best practice guidance on how to manage HIUs, ultimately seeking to improve the culture in the departments. Whilst working on a new project during the COVID-19 pandemic offered a series of challenges, more than 140 HIU have been engaged across the five adopting EDs.

Interim data demonstrates the following impact on patients:

  • A 44% reduction in the number of ED attendances following the first month of engagement for 89% of the patients engaged.
  • The remaining 11% of the patients saw a significant escalation in their behaviour, however it is broadly acknowledged that the highly complex nature of these individuals often means that where attendances cannot be reduced, the teams are there to provide appropriate support and improve the experience of the patients and staff members alike.

Additional data collected by several trusts demonstrates that where attendance had increased, the impact and cost of each attendance had reduced.

Feedback from a 2021 staff experience survey included:

  • “Dedicated HIU teams are making a real difference to the appropriate management of these patients.”
  • “Our HIU team are brilliant and have made a huge impact on not only the number of attendances but patient outcome and reduction in violence and aggression cases.”

A project evaluation, which will seek to fully understand the effectiveness of the SHarED model is expected in Autumn 2022.

“The West of England AHSN are proud to have supported the adoption and spread of the HIU model across our region. The project has flourished despite the challenges presented by the pandemic and that is a testament to the dedication and hard work of everybody involved – especially the staff in ED teams. The commitment to appropriately supporting this most vulnerable of patient groups has been exemplary.”

 Clare Evans, Programme Manager for SHarED and Deputy Director of Service and System Transformation, West of England AHSN

Next steps

While the West of England AHSN funding has now ceased, the ED teams are working with their trusts to secure ongoing support. Each team are passionate about continuing the important work that has been started by the SHarED project.

The West of England AHSN are looking forward to the seeing the full project evaluation, which will seek to fully understand the effectiveness of the SHarED model. We expect to receive the completed evaluation in Autumn 2022.

The majority of the West of England AHSN involvement in the project was from 2019 to 2021.

Find out more about SHarED on our website or by contacting Megan Kirbyshire, Senior Project Manager, West of England AHSN

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