Supporting Elderly Patient in Chair

Resource matching and e-referrals with Palliative Care and Care Homes across Cumbria

Transferring patients from one kind of care to another is a complicated process. Failures in coordination between care providers can seriously affect patient safety. “Strata” is a software programme that allows care providers to see a full directory of services available in their region. Patients’ needs can then be matched to the most appropriate service available and an electronic referral (e-referral) can be made in a timely manner. This project supports the implementation of the Strata e-Referrals and Resource Matching system to hospices, specialist palliative care teams & residential and nursing care beds across Cumbria.

Cumbria CCG is the first commissioner to introduce a proven software into the NHS as the common e-referral and resource matching system across all health and social care providers in Cumbria.

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Prior to the referral system we spent one morning a week going through errors and issues with referrals. Now issues are immediately highlighted and an audit trail ensures we can rectify these quickly & transparently.
Nick McCarthy, Team Manager, Cumbria Social Care
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Inadequate systems for the transition of patient care can compromise patient safety. Across Cumbria there are at least 250,000 transitions of care per annum.  Common care transferral problems include: a reliance on outdated paper, fax and telephone systems; delayed transfers of care; high levels of re-admissions to hospital within 30 days; and longer lengths of stay in hospital. Furthermore, health and social care staff are unable to see which community based services are available, what the capacity of these services is and whether any beds are available in hospices and care homes.

A number of national reports highlight the need for electronic referrals to be made between care providers to improve communication, as well as the quality of patient data. This can be achieved using the “Strata” software programme. Strata is designed to enable health and social care providers to see the current available beds and places in hospices, care homes and capacity in specialist palliative care teams. Patients’ needs are then matched to the most appropriate service available and electronic referrals are made. This enables prompt discharge from hospital to the most appropriate care setting for patients. The software is integrated with the patient’s electronic record so patient data is up to date.

As a result, patient flow between acute and community based services is greatly improved, as is communication between these services and teams. Health & social care providers will also be able to improve end of life care planning for their patients. Cumbria CCG is the first commissioner to introduce this proven software into the NHS. It will be used as the common e-referral and resource matching system across all health and social care providers in Cumbria.

  • The Strata software programme greatly improves the transition of patients between care providers, allowing for safer and more efficient patient care.
  • Staff can see the real-time availability of resources and beds and pro-actively match these to patient needs.
  • Record keeping is improved due to integrated digital care records that can be shared across care providers and the quality of patient data is improved.
  • Staff time can be re-directed to patient care rather than complex administrative processes.
  • Paper and fax costs are significantly reduced generating real cash savings.
  • Implementation will lead to earlier discharges from hospital for patients, thereby reducing the risk of healthcare acquired infections, pressure ulcers, medication errors, malnutrition, loss of independence & psychological upset.
  • Since going live with the system (09/15 – 10/16), 588 electronic referrals have been made to palliative care (546 e-referrals) and care homes (42 e-referrals). 174 beds have been booked through the electronic resource matching system. St Mary’s Hospice has received 309 referrals with an average response time of 28 hours.
  • Cost savings are estimated at £23 per referral: £1 per referral saved in terms of paper/fax/telephone costs; £13 per referral in staff time saved by sender; £9 per referral in staff time saved by receiver of referral.
  • To patients: Better, safer and more appropriate care, less time in hospital, more quality care time with care staff.
  • To staff: Smoother and safer transfer processes, less administrative work, more time with patients, improved patient data quality.
  • To Trusts and CCGs: Integrated patient records and improved patient data, more coordinated and accessible care across the region, savings from reduced hospital time and stationary/administration costs, improved patient and staff wellbeing.
  • NENC AHSN and NWC AHSN have worked collaboratively, with Cumbria CCG and its provider organisations, to fund and support the roll-out of the Strata software programme.
  • The AHSN NENC provided support for patient flows across North Cumbria (£95,000), whilst NWC AHSN (£115,000) covered the equivalent in South Cumbria and North Lancashire.

By the end of 2016, we anticipate that all staff involved in palliative care services across Cumbria will be using the system. The system is also being opened up to general practices to make referrals into End of Life care services.

Cumbria County Council have committed to getting all 5000 commissioned care home and intermediate care beds onto the system; to date 591 beds from 22 care homes have been included.