Rebekah Matthews is an Integrated Pathway Manager at Firth Park Clinic, Sheffield Teaching Hospitals NHS Foundation Trust. Her role involves managing one of Sheffield’s four localities of community nursing teams.

‘I trained to be a nurse in Leeds, qualifying in October 1994. I knew very early in my nurse training that I wanted to be a community nurse, having had some fantastic placements in the community setting. I started my first job in the community as soon as I completed my training, and went on to complete the District Nursing Specialist Practitioner Qualification in 1999 in Manchester. You could say that my 23+ years of nursing in the community has given me a real passion for providing safe, high quality care for some of the most complex and vulnerable people in our community, in their own homes.

In July 2015 I developed the concept of the Okay to Stay plan to help us enable and support patients with complex long-term conditions stay at home and avoid unnecessary days in hospital, and help facilitate earlier discharge home. I wanted to see if we could find a better way to support patients at home, even if they become unwell. It all started with a workshop I arranged with geriatricians, ward matrons, hospital and community therapists and nurses, GPs, social services and the Yorkshire Ambulance Service.

Everyone was enthusiastic and during the workshop we started to develop the plan, which has been developed and operationalised by an ongoing steering group. We also involved patients and their families in the development of the plan from the outset.

The Okay to Stay plan has developed into simple document drawn up by a community matron with the patient. As well as including vital medical information, it paints a picture for any visiting health professional of how the patient manages at home, who supports them and what medication they need, including rescue medications if they become unwell. It also helps the patient to recognise an exacerbation of their condition and when/how they need to take their emergency medications.

The plan is completed on SystmOne (our clinical patient record), and is accessible via our Single Point of Access. It is recommended that the plan is reviewed every three months, or if there are significant changes. The patient and/or their family retain a printed copy, which they are then able to share with paramedics, the ambulance service or emergency department staff.

The Okay to Stay plans encourage the development of a holistic action plan to help in the event of the person becoming more unwell. When completing the plans it adopts an enabling and self-help approach, and aims to increase confidence for patients and carers to manage their own conditions and access expert help at the appropriate time.

More recently we have started working closely with independent living advisors from AgeUK, who work closely with the community matron to complete the more social aspects of the plan with the patient. This has proven beneficial for the patients, as they have been able to identify and resolve issues such as finances, benefits, heating and social isolation.

The plan is now widely recognised and used in Sheffield. There has been agreement from the CCG for the Okay to Stay plan to link in and complement the Person Centred Care Locally Commissioned Scheme, aimed at developing a systematic person centred approach to the management of all long term conditions. This is a significant development in supporting the adoption of the plan across Primary Care.

The initial evaluation saw a 40% reduction in hospital admissions for the first 36 patients in the pilot; further statistical analysis by the University of has shown that the plan is effective in reducing visits to the emergency department and unplanned hospital admissions in people with long-term conditions.

We now have around 200 plans in place and we estimate that up to 2,000 patients in Sheffield could benefit from having a plan. This potentially saves money by reducing avoidable hospital admissions, but which more importantly is better for the patient too. During the evaluation, patients said they felt more confident and supported, and were more aware of when they needed to go to hospital and when they could stay at home with support. It wasn’t just the piece of paper that gave them the confidence; it was their interaction with the nurses involved.’

If you have any questions about anything in this blog please contact Rebekah directly: rebekah.matthews@nhs.net

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