CHART Team

Care Home Assessment and Response Team (CHART) Story

Background:

In March 2020, at the outset of the COVID19 pandemic, some care homes within the Forth Valley area of Scotland had significant outbreaks of coronavirus with many residents affected, some of whom were dying.   There was an immediate response from social care, GP practices, Ageing and Health, ‘Out of Hours’ services, public health, care inspectorate, hospice and voluntary agencies to support these care home residents and the staff working within them. Initially the co-ordination of this response was poor, and as a result care homes were phoned numerous times a day by different organisations asking similar questions.

In April a decision was taken to co-ordinate the support for care homes in Forth Valley through a dedicated multi-professional and multi-agency team called CHART (Care Home Assessment and Response Team).

This CHART team was formed of different professionals that included GPs, social care workers, palliative care specialist nurses and Advanced Nurse / Paramedic Practitioners. The associate medical director for primary care initially engaged a small and regular cohort of GPs for continuity and consistent clinical leadership. The FV Advanced practice lead resourced and co-ordinated ANPs from throughout the organisation including acute care, community hospitals, prison health services and primary care.   We also integrated ANPs who were unable to undertake patient facing work to join the team in Stirling and engaged with those ANPs shielding at home. These ANPs undertook telephone triage and also provided care homes with follow up calls. As well as this they were able to provide clinical advice or prescriptions over the phone or undertake ‘near me consultations’ where available.

The daily ‘TEAMS’ video-call with those shielding was linked in with the wider care home liaison ANPs and helped this workforce feel integrated as very valuable members of the team.  

Together CHART supported the 2000 residents living in the 66 care homes across NHS Forth Valley.   There are 2 health and social care partnerships within NHS Forth Valley.  The health and social care professionals working within the CHART team were physically co-located in Stirling Community Hospital, and held a daily morning call with the Falkirk Social Care team.  

The team actively visited some of the sickest people who were affected by COVID19.  This involved putting themselves at increased risk of infection from visiting care homes with known outbreaks of coronavirus, at a time when everyone was getting used to using PPE. They assessed those with symptoms of COVID19, using emerging central guidance and tools.   They kept anxious families and loved ones informed and aware of what was happening – which was particularly important when families were not able to visit the care home.  They were involved in making difficult decisions about whether residents required admission to hospital, and provided good palliative and end of life care for those dying from the effects of the virus.

Coming together from so many different disciplines, as a new team was a challenge.   However the depth and breadth of the health and care experience within this new team was immediately evident.   There was a clear common purpose which immediately focused minds.

A decision to co-locate the team together within Stirling Community Hospital was tremendously important.   It allowed the healthcare staff and social care staff to work together and discuss how they would co-ordinate support for the care homes.   This also allowed a much greater understanding of the individual roles of everyone involved and helped recognise their unique contribution.   As well as the regular daily meetings, the ability to eat lunch together and share a (socially distanced) chat over a coffee and a biscuit, enabled the professionals from health and social care to get to know each other much better, strengthening the team. 

Senior support from within the health and social care partnerships was ever-present, and responsive to the needs of the team. The CHART team was able to discuss requirements, and make operational decisions regarding the running of the service, without the need to go through protracted governance procedures.This allowed for the development of a responsive service within which was able to meet the needs of the care homes and their residents.

Objectives of CHART:

The agreed objectives of the multi-agency response, leading to the formation of CHART, were to:

• Support care homes with infection control and other measures to protect their residents
• Encourage completion of Anticipatory Care Plans
• Ensure rapid access to appropriate medication for symptom control
• Allow GP practices to separate COVID clinical work from the non-covid work
• Provide responsive assessment and management of symptomatic residents
• Improve quality of care within care homes
• Enhance quality communication between agencies
• Support Care Homes to develop manage and sustain resilience and recovery planning.

Activity:

All care homes in Forth Valley were provided with a single phone number to call between 8am and 6pm, 7 days a week.   This number could be called regarding any clinical concerns or for advice in relation to COVID19, and the call by-passed their normal GP practice.This then prompted either a video or telephone call with one of the advanced nurse practitioners working with CHART. One of the team could then visit the symptomatic care home resident within the home as required. Colourful posters and flow-charts were produced and circulated to all care homes advertising the new service.

Every morning, a social worker proactively called each care home on a multi-agency basis to provide advice and support, and to check how things were going.  Any clinical concerns were discussed with the clinical component of CHART. The social care staff were able to identify any staffing, infection control, or welfare issues and take the appropriate action to support the care homes.

At the end of each day there was a multi-agency Forth Valley Care Home Strategy Group meeting, led by the Nursing and Public Health directorates – which involved the care inspectorate, CHART, the care home assurance team, senior management and other key stakeholders.   The care home strategic group was able to mount an immediate response within 24 hours to address any concerns raised.

The integration of social care and health care professionals within one team allowed for the sharing of relevant information to support care home residents and staff in a proactive way.  Low level concerns that may not have been reported formally were shared within the team to enable an appropriate response.These included observations about infection control procedures within a home, and where it was felt that care home staff needed additional support.

In the early months of the pandemic there was a focus on updating Anticipatory Care Plans and the sharing of information on the Key Information Summary. This was largely undertaken by the care home staff and care home liaison nurses.The social care component of CHART prompted care homes to focus on this during their daily calls, and the clinical members of the team were there for support and guidance. Education and training sessions on Anticipatory Care Planning, and the use of the ‘ReSPECT’ approach was provided.

Activity and Outcomes following establishment of CHART:

There were 178 referrals to the clinical component of CHART regarding 91 different residents over during the first 10 week period of operation (April to June 2020), due to care home residents experiencing symptoms or signs of COVID19.   34% of these residents were ultimately tested positive for COVID19, and 66% tested negative.  This suggested that the referral flow chart was successful in identifying those that were most likely to have COVID19.

An active and complete Key Information Summary was found to be available for 79% of residents at the point of referral.  Specific outcomes following intervention from the clinical component of CHART included:

49% of all calls were resolved with advice to the care home staff on management

22% of calls resulted in an antibiotic being prescribed

15% of all calls resulted in a palliative and approach to care with end of life care support

12% of calls resulted in other medication (not antibiotic nor palliative care medication) being prescribed

4% of calls were passed onto the GP practice for non-covid conditions that required ongoing treatment

2% of calls resulted in treatment with portable oxygen within the care home setting

2% of calls resulted in an admission to hospital

1% of calls resulted in a referral to the Respiratory Team

Feedback from key stakeholders

Because this was a newly formed team, responding to a pandemic which had not been experienced before, feedback was actively sought from internal and external stakeholders.   This allowed the team to evolve and develop in an iterative constructive manner.  As well as regular informal feedback, questionnaires were sent to the following groups of people (Care Home Staff, Care Home Liaison Nurses, Social Care professionals, GP practices) to explore their experience of working with the CHART team.

A summary of the responses is given below:

1. Feedback from Care Homes

17 Care Homes returned a questionnaire summarising their experience of working with the CHART team.   Figures 1 and 2 below show that care homes felt that communication and information was provided by the CHART team in a professional and supportive manner (47% strongly agree and 40% agree).   Particular appreciation was shown for the proactive daily calls from the social care component of CHART, with 87% of care homes agreeing or strongly agreeing that they felt supported and were listened to.

Figure 1: Care home feedback on communication with CHART

Figure 2: Care Home feedback on Social Care CHART