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Increasingly, healthcare analysts are realising the importance of providing medical services in the community, as lengthy hospital waiting lists and rising trolley numbers continue to place pressure on secondary care services.
Most healthcare experts accept that placing a renewed focus on community care is essential for the future of our healthcare services, with hospital attendance and admission set aside for the most serious cases.
As far back as the 2001 Primary Care Strategy, successive Ministers for Health have placed an emphasis on providing care to patients as close to home as possible.
One of the many principles outlined in the Strategy is the development of rapid-response community intervention teams (CITs).
The main aim of CITs is “the avoidance of unnecessary hospital attendance or admission and the facilitation of early discharge from hospitals”, according to a 2011 HSE document on CITs.
The document explains: “The capacity of community services to provide a rapid response to patients in the community who present with new or enhanced needs, particularly during out-of-hours, is limited. This can result in patients presenting at acute hospitals, whereas their care could be managed in the community with appropriate input from nursing and other care services. It can also lead to patients remaining in hospital when they are fit for discharge home. The development of CITs will address these issues through fast-tracked provision of care and supports while mainstream services are being arranged for the patient.”
The first CITs were established in 2006, with four teams put in place amid plans for eventual national roll-out of teams.
The development was heralded as a major success for the HSE, which had been working on establishing the teams for a number of years.
But despite much enthusiasm surrounding the new teams, no more were established for several years and development of CITs slowed considerably as healthcare budgets tightened following the economic crash.
Initial uptake was below par and concerns emerged around high costs associated with the service. However, patient satisfaction was very high and the teams aided in saving a significant amount of bed days (see panel below for more detail).
The need to avoid unnecessary hospital attendance has never been more acute, as winter 2015/2016 has seen more overcrowding in hospital emergency departments (EDs), with stories of elderly, infirm patients waiting on trolleys, many for over 24 hours, making the headlines.
According to Irish Nurses and Midwives Organisation (INMO) figures, the number of patients awaiting hospital admission while on ED or ward trolleys was over 500 per day for much of the past six weeks. On 5 April some 533 patients were on trolleys and the number of ED attendances has increased by around nine per cent this year.
It is clear that CITs have the potential to save hospital bed days and facilitate early discharge, thereby reducing spiralling hospital costs. But what impact, if any, are CITs now having on alleviating pressure in hospitals and is the service being used as intended?
How CITs work
According to the HSE the definition of a CIT is: “a specialist nurse-led health professional team, which provides a rapid and integrated response to a patient with an acute episode of illness who requires enhanced services/acute intervention for a defined short period of time. This may be provided at home, in a residential setting or in the community as deemed appropriate, thereby avoiding acute hospital admission or facilitating early discharge. CIT personnel have a strong liaison role with hospital and community clinicians and provide services in the patient’s home, primary care centres, and in both public and private nursing homes”.
CITs are essentially designed to provide short-term assistance to patients for usually no more than a 72-hour period. Access to services, such as nursing and home care support, is provided from 8am to 10pm, seven days a week.
The CITs provide a range of services including administration of home IV antibiotics, ie, outpatient parenteral antimicrobial therapy (OPAT), acute anticoagulation care, acute wound care and dressings, and enhanced nurse monitoring following fractures, falls or surgery.
CITs also provide care of a patient with a central venous catheter; urinary related care; care of the patient with a respiratory illness; bowel care including ostomy care; short-term older person support and care; and other medication management/administration as part of a patient’s acute intervention package.
The number of staff on CITs varies but a team usually consists of a nurse manager/coordinator, general nurses, healthcare assistants, and clerical administration staff.
All teams are run and operated differently, with some HSE-delivered and falling under the auspices of GP out-of-hours services like Southdoc, while others are externally delivered.
Referrals can be made by a number of medical practitioners, including hospital doctors, GPs and nurses, as well as health and social care professionals.
Referrals can come from services within acute hospitals, community hospitals, community nursing units, public health nursing, out-of-hours GP services, and primary care teams.
The OPAT service commenced in 2011 and in 2014 a decision was made within the HSE to amalgamate the CIT and OPAT services and the partnership has since been completed.
Speaking to the Medical Independent (MI), Ms Noreen Curtin, HSE CIT OPAT Programme Manager, explained that IVs are a small part of CIT activities, but receive a lot of attention.
“Even though it’s a small portion of referrals to CITs it gets a lot of attention because it’s a definite bed-day saving. In other types of patients you see it’s harder to say how many bed days you’ve saved… you can’t be as definitive,” she remarked.
Ms Curtin revealed that over 26,000 bed days had been saved thanks to OPAT last year, which is an average of 73 beds a day.
There were 19,675 patient referrals to CITs in 2015, including around 1,000 OPAT referrals.
Overall, CIT referrals rose by 33.9 per cent last year compared with 2014 when referrals totalled 14,689. The HSE expects referrals to increase to 24,000 in 2016.
There are around 400-self/patient carer administered OPAT (S-OPAT) referrals annually.
Separately, there are around 400 S-OPAT referrals for patients with cystic fibrosis every year.
The total number of GP referrals to CITs in 2015 was 4,200, according to the HSE.
It is now 10 years since the first CIT was established in Cork and teams are still not in place countrywide.
There are currently 11 permanent CITs and two short-term CITs in place nationally. Nine are externally provided and four are HSE provided.
The permanent teams are located in Dublin North, Dublin South, Kildare, Louth, Meath, Wicklow, Carlow/Kilkenny, Midwest (Limerick, North Tipperary, and Clare), Cork, Galway, and Waterford.
A CIT commenced on a short-term basis in South Tipperary on 20 January 2016 and another short-term service recently commenced in Sligo.
‘There is a feeling we as GPs are perhaps underutilising the service’
Ms Curtin explained the interim teams were established to respond to an immediate need for assistance.
“In response to demand in January as regards the pressures on hospitals, teams were put in there, but at the moment we don’t have full-year funding,” Ms Curtin advised.
She confirmed there is currently no full-year funding in place to establish more permanent CITs in these areas, despite demand.
A CIT in Waterford came into operation late last year after a tender notice was issued by the HSE in October last. The HSE said the CIT would improve access and capacity within University Hospital Waterford (UHW), where admission avoidance measures such as rapid access clinics are in development.
The last 18 months has seen a big jump in CITs nationally, with the majority of the extra teams coming on stream during this time.
Ms Curtin told MI that a number of developments have been taking place, including the coming together of teams for information sharing meetings every two to three months.
The workshop team meetings allow teams to share information and ideas. Patient case studies are presented and understanding of definitions, standards, and activities are shared to help provide a framework for newer teams, Ms Curtin explained.
The HSE maintains it is looking to standardise the service nationally and enhance service integration. An oversight group for CITs is in place with representation from the acute hospital division, social care, the clinical programmes, and primary care.
In addition, the HSE is working on introducing a standard CIT referral form and plans to introduce electronic referral for CITs by the end of the year.
However, there are “no immediate plans” for more teams this year, Ms Curtin admitted.
She declined to reveal the HSE budget for CITs, citing commercial sensitivities due to a number of teams being provided by external companies.
However, she said the budget for CIT and OPAT services had increased in recent years to allow more teams to be put in place.
The average cost of a CIT nurse varies depending on the complexity of the service/procedure being provided, according to the HSE.
The HSE estimates that the current average cost is €108 per visit, with some infusion procedures necessitating more nursing input.
It is understood that when CITs were first established the cost per visit was around €250.
The HSE vision for national rollout of CITs remains, but Ms Curtin acknowledged that a definitive number of teams to achieve national roll-out has yet to be determined.
“Our vision would be for national roll-out and that’s something that we’re working towards,” she said, adding that the exact number of teams nationally depended very much on geography.
“It might make sense in the future that you would have Laois/Offaly together for instance. Donegal would probably be one team,” she outlined.
There has been no formal recording of patient feedback to the HSE CIT service but the company running the OPAT service has had very positive feedback, Ms Curtin stated.
Feedback to the OPAT service is consistently 90 per cent or higher as patients prefer being at home rather than in hospital, she said.
Although the number of teams has increased and uptake is rising, concern remains around knowledge of CITs among medical professionals, particularly GPs, and how much the service is utilised.
Referral terms for CITs state that GPs can refer to the service, but most referrals come from hospitals and are requested on hospital discharge. The referring physician retains responsibility.
North Dublin GP and former IMO President, Dr Ray Walley, said that once a GP refers a patient they have a duty of care to continue to manage their condition.
Dr Ray Walley
GPs can charge private CIT patients for a day visit but are unable to charge medical card patients, Dr Walley explained, adding that this is an indication of how service provision in deprivation and rural areas is under resourced.
The Dublin North CIT is one of the busiest in the country, the HSE told MI.
Cork GP Dr Ciaran Donovan, who works at a large GP practice in a deprivation area of Cork with around 7,500 patients, said that they have had “minimal involvement” with the local CIT, in operation for 10 years now.
Dr Ciaran Donovan
Dr Donovan said he does not use the service, that it had not been promoted to the practice in recent years and that he is unsure of how to access the CIT.
He suggested that perhaps GPs are wary of the service, which in theory should have no GP involvement in terms of service provision.
“We initially thought it was a back door to GPs doing more work in the community with no extra money,” Dr Donovan remarked.
Cork GP Dr John Sheehan told MI that he finds the local CIT very helpful but suggested the service is perhaps a little underutilised by GPs.
In his view, the service has expanded to now provide services like phlebotomy, catheterisation, and home IV antibiotics.
“We find it very useful as a stop-gap measure,” he remarked.
“Their role is expanding now and we find that very good.
“There is a feeling we as GPs are perhaps underutilising the service. We sometimes don’t realise they’re doing so much and we probably haven’t embraced their enhanced care role.”
He added that HSE personnel recently visited his practice to provide an update on the services provided by the CIT and its role in the community, which he found very useful.
Walkinstown GP Dr William Behan said he has found his local CIT “flexible, very patient-friendly and reliable”.
His experience of the service is that it is very much hospital organised. He said that he has to refer a patient to hospital before they can access a CIT.
“I find it very useful for patients who have been discharged from hospital on warfarin,” he commented.
A public tender notice outlining the HSE’s interest in seeking a provider to supply a management control centre (MCC) for CIT and OPAT services was posted online recently.
The notice states the HSE’s intention to establish a contract with an external provider to manage patient referrals to CIT and OPAT services in Ireland via an MCC.
The notice reveals that a contract for an OPAT service was established in January 2013, including: “The provision of a service to manage and co-ordinate patient referrals to the OPAT programme including a patient care bureau, online patient referral system, patient helpline. and detailed performance reports.”
“Some 5,680 referrals were managed successfully through the national OPAT service in the first 33 months of the programme. The service averages 195 referrals per month (based on the last 12 months).
“Externally contracted CIT services in Galway, Louth, Meath, and Kildare are supported by the MCC. Referrals to the other CIT services will be incorporated in the next phase of development of the MCC,” the notice added.
“The MCC will provide a clinical and pharmaceutical review of the appropriateness of all patient referral requests to the CIT/OPAT programme. The HSE will identify patients for discharge to each service and will submit a patient discharge request via an online technology solution, which will be provided and managed by the provider of the MCC.”
CIT services — a journey back in time
It is now 10 years since the launch of the HSE’s CIT project.
In late 2005, the HSE PCCC Strategic Review and Implementation Steering Group earmarked three priorities for 2006 as part of the phased implementation of the revived Primary Care Strategy. One of these priorities was the implementation of CITs. According to the HSE, the limited capacity of mainstream services to provide an immediate response to patients in the community, particularly the elderly and disabled, who presented with new or enhanced needs, led to the proposal for CITs.
The CIT service was to provide a rapid response from community services to patients where it was deemed medically suitable that their treatment could be provided in a home setting so that: Unnecessary referrals to EDs and/or other hospital services could be avoided; patients could be cared for at home in their community, where most prefer to stay; and early discharge from hospital could be facilitated.
CIT staff were to include general nurses, public health nurses, and home care staff, and could be accessed by participating GPs and EDs.
This staffing complement was to be spread over a seven-day service, between the hours of 8am and 10pm or midnight.
Four ‘learning location’ sites were chosen for the initial roll-out of the teams in 2006. These sites were to be used as the basis for a national roll-out of the initiative.
The first CIT was launched in Cork in May 2006, while the Limerick and Dublin North services commenced in early November 2006 and the Dublin Mid-Leinster service commenced in mid-December 2006.
Like many new HSE initiatives the teams were slow to take off and the initial uptake of their services was poor.
The four CITs had a combined capacity to treat 90 patients a week but by the end of April 2007 three of the CITs were treating less than a third of their weekly patient capacity and one team was treating half of the patients it could potentially cater for on a weekly basis.
The total number of referrals to the four teams, up until February 2007, was 274, with 50 per cent of patients being referred from EDs, and the remaining 50 per cent from participating GPs.
An evaluation of the CITs was due to be finalised by the end of the summer of 2007 and this report was to help determine the way forward. However, no announcement was made in 2007 about the future development of the teams.
At that stage there were emerging concerns about the cost of the teams relative to the number of patients they were treating, though patient feedback was very positive.
Information received through Freedom of Information legislation revealed that the four CITs cost a total of €2.158 million up until the end of September 2007, to treat just 2,216 patients.
When total costs were divided by the total number of patients treated, the average cost per patient treated by a CIT was €974. However, when the four team figures were broken down individually, the average cost per patient for the Cork CIT was €1,780, almost double the average figure, while the most economical CIT was the Dublin South one where the average cost was €667 per patient.
The Cork CIT team also had the highest wages bill at that stage.
Meanwhile, a HSE evaluation of special initiatives was completed in 2008, which made recommendations with regard to the continuation, development, and potential expansion of CITs.
However, no new teams were launched in 2008, though innovation funding led to an expansion of the capacity of the CIT service in the greater Dublin area. This increased the level of throughput by extending the catchment area and the range of clinical conditions accepted by the service.
Between January 2007 and May 2009 a total of 11,062 patients were treated by the four CIT services. This worked out at around 380 patients per month within the four teams.
Approximately half of patients were ‘hospital avoidance’ while a third were ‘early discharge from hospital’, yielding a significant number of saved bed days.
Private CIT services
Homecare services similar to those supplied by CITs are provided by private operators like healthcare insurance company Vhi Healthcare.
According to Dr Bernadette Carr, Medical Director, Vhi HomeCare, the company’s service was originally established in 2010 on a pilot basis linked with Dublin’s St Vincent’s University and Beaumont Hospitals.
“Last year over 950 patients were referred to the service. Last November, VHI HomeCare reached a milestone in treating its 5,000th patient,” Dr Carr stated.
“Since the service was established it has saved 65,000 hospital bed days and cost savings associated with those bed days are in the region of €27 million.”
According to Dr Carr, what sets the Vhi’s service apart from many other models is the fact that it is consultant-led.
“This offers a number of advantages in that it ensures the service has strict clinical governance. Weekly clinical meetings similar to hospital ward rounds occur to determine the best course of treatment for all patients using the service. Each patient admission is unique depending on the nature and severity of their illness but most patient treatment would last a number of days.”
There is no direct cost to Vhi customers as the service is covered as part of inpatient insurance benefits.
This Hospital-in-the-Home Service is an alternative to provide Vhi customers with access to high quality care delivered in the comfort of their own home. Some hospital consultants believe it is more appropriate to treat some patients at home rather than in a hospital setting, Dr Carr outlined.
Initially, the service covered Dublin, Wicklow and parts of Louth, Meath, and Kildare. It now covers all of Meath, Kildare and most of the east coast from Dundalk to Gorey in Wexford.
According to Dr Carr, the service began providing IV antibiotic treatment for patients with pneumonia, cellulitis, and urinary tract infections and also for patients who required anti-coagulation therapy.
“This is still the most common treatment provided today with the service expanded to include: endocarditis; osteomyelitis; septic arthritis; kidney abscess; and diverticulitis. Patients requiring negative pressure therapy and also patients who required stoma and drain care can also be treated by the service. Another important treatment offered by the HomeCare service is the provision of total parenteral nutrition (TPN) for cancer patients and also for those with gastrointestinal issues.”