With winter looming, health and care teams are being urged to radically overhaul discharge procedures to prevent patients being left stranded on hospital wards. New approaches are yielding striking results that could help avert a beds crisis – and improve older people’s chances of continuing to live independently.
The latest thinking on hospital discharge is to get people home and then carry out assessment of their support needs and rehabilitation. Hospital trusts and their community health and social care partners are being encouraged to adopt a “discharge-to-assess” (D2A) or “home-first” model.
Where the models have been tested, the number of patients subject to delayed discharge has plummeted; the number of patients going into residential care has also shrunk dramatically – in one instance, almost to nothing.
“We can see that the impact of D2A is huge,” says Liz Sargeant, clinical lead for the national emergency care improvement programme. “Ten days in bed for patients over 80 is equivalent to 10 years’ ageing of muscles.”
This deconditioning means that some people go into hospital never to see their own home again. “Yet people can instead be discharged, then supported in their own homes,” says Sargeant.
Images of people waiting for trolleys in A&E and reports of routine operations being cancelled dominate the news every winter, as demand for hospital beds spikes. Nearly two thirds of hospital inpatients at any one time are 65 or older, according to the National Audit Office, while delays in discharge, or “transfers of care”, are almost a third up on 2014. That’s equivalent to almost 6,000 beds a day being taken up unnecessarily, with 55% of delays attributed to the NHS – principally “patients awaiting further non-acute NHS care” – and 37% attributed to social care, principally patients awaiting a care package for when they return home.
Measures announced in July aimed at prompting councils to cut delays on the social care side have proved controversial. Critics have questioned the rationale of threatening to cut funding for councils that fail to respond. But part of the drive to free up as many as 3,000 extra beds is based on an expectation by NHS Improvement (NHSI), the agency that works with care providers, that hospitals will adopt the D2A model as good practice and have just one person carry out needs assessments.
The agency points to results in east London, where Tower Hamlets Together, a collaboration of health and social care organisations, has piloted D2A. The average length of hospital stay is down and there has been a dramatic fall in the number of patients ending up needing long-term care, says Patricia Oguta, interim team manager for hospital social services.
When the pilot was run in 2015-16, just 1% of patients who were discharged under the new arrangements, then assessed at home for care packages, reablement and therapy, ended up in residential or nursing care – compared with an estimated 50% of patients who had conventional in-patient rehabilitation.
The approach is now a formal “care pathway” within the admission avoidance and discharge service operated by the East London NHS foundation trust. Running seven days a week from 8am to 6pm, it is staffed by two social workers, four occupational therapists (OTs), two physiotherapists, three nurses and one rehabilation support worker. Patients are given an assessment on the day of referral, if required, and receive up to six weeks’ community input post-discharge. Short-term night care is also possible. The full social care assessment process starts two weeks after discharge, to fully address the change in needs.
“Tower Hamlets’ success has been down to partnership working and a whole-system approach, with a big emphasis on supporting people in their homes,” says Oguta. “As a result there are fewer people going into residential care and we have been able to close one of the rehabilitation wards for the elderly.”
Another success story is in Kent, where Medway foundation NHS trust has shown what can be achieved with the right mindset. The trust came out of a record four years in special measures in April after overhauling its discharge arrangements. Working in partnership with Medway clinical commissioning group (CCG), Medway council and Medway Community Healthcare, a community interest company, the trust developed the Home First initiative – to provide support for patients who are medically fit to be discharged, but still require additional home support.
Again, results have been astonishing – a 25% drop in the number of delayed transfers of care in three months of the pilot last year, with an average of 32 patients discharged by the Medway Maritime each week. That number has since increased to 40, and a total of 2,000 patients have been discharged under the seven-days-a-week scheme, which has four patient pathways, for those needing little or no support through to those with complex needs who may need intermediate care and may not be able to go home safely immediately. Data shows permanent admissions to care homes for over-65s have halved since introduction of the scheme.
Barbara Littlewood, 87, from Allhallows, near Rochester in Kent, is a fervent advocate of Home First. She was supported to return to her bungalow last winter, following surgery on her knee, and spent just five days in hospital, compared to three weeks for a similar operation in the past.
“I can never sleep in hospital so I was relieved to get home,” says Littlewood. “I had carers in three times a day and an OT came to oversee my exercises. Everyone made sure I had all I needed to get around my home safely and independently.”
Lisa Riley, former Home First lead for Medway Community Healthcare, who now works with NHSI, recalls that Medway’s D2A scheme was implemented in April last year just a few weeks before a visit by inspectors from the Care Quality Commission. It used existing teams and directed all care via that route – removing historical “territories” and creating a single point of access for all coordination of a patient’s discharge. Under the new system, transport is arranged for patients, who are assessed in their own homes by an OT within two hours of leaving hospital. The care package may also involve telecare and wraparound care, with people ringing to make sure medication is taken.
Riley, who has spoken to 30 other health and social care organisations about the Medway approach, admits that one model won’t suit every situation. However, she believes the key is to make it as simple as possible and ensure that someone has leadership of the overall project, as well as giving control to staff.
There is no doubt that the Medway model has involved a huge culture change. Borne out of necessity, with the trust needing to improve on its special measures rating, Home First was implemented throughout the Medway Maritime hospital. The success of the scheme shows how it is possible to make change within current systems. By placing a greater emphasis on an individual patient’s needs, rather than on organisational boundaries, and by making imaginative use of money, resources and skills across established silos, the Medway did enough to elevate itself out of special measures.
Sarah Mitchell, a former director with the Local Government Association, who is now strategic adviser for social care for NHSI’s emergency care improvement programme, agrees that cultural change is essential. But she stresses that money needs to be put into community health services to support the change. “There is a focus on front-door services, but the availability of district nurses and assistant nurses reduces pressure,” says Mitchell. “If you want the community to do this, you have to invest in this.”
The case for pushing people, within their capabilities, to do more for themselves, so that they avoid becoming dependent is “overwhelming”, says Sargeant. “We ask people to make cups of tea in hospital occcupational therapy kitchens and walk upstairs, even if they live in a bungalow or on one level of their house,” she says. “We ask them intimate questions about how they manage their personal care and then decide whether they have passed or failed these tests. For people with dementia, this is even more challenging.
We would not keep children in hospital unnecessarily, she adds, so why do so with older people? “We need a cultural change; we need to develop a home-first mindset. It is happening in some places, but there is slow progress in others. It needs to happen everywhere.”
‘They are talking about a walk-in shower’
Marlene Decozar was celebrating her 80th birthday surrounded by her close family at her home in east London earlier this year. Days later she was on a hospital ward because of a spinal fracture brought on by thinning of the bones.
Confused and in extreme agony, she had been taken by ambulance to the Royal London hospital. Yet within a week, she was back at her one-bedroom home in Poplar with the support of the Tower Hamlets reablement team.
“In hospital they got my pain under control,” Decozar says. “They then sent different services to see me and follow up back at home. I still have to have help getting in and out of the shower as I can’t bend.
“The occupational therapist comes once a week and they are even talking about getting me a walk-in shower, which will be brilliant,” she adds.
For daughter Lisa Warren, who lives in nearby Hackney, the care has been an eye-opener. She says: “I thought my mum would be stuck in hospital for weeks.
“The reablement team has been supporting her to be independent. They are talking about fitting a wet room and they have given her a tray on wheels, so she can make herself cups of tea etc. I was worried that she would get six weeks of care and that would be it. But the support has been ongoing. Carers come in and the team has extended the help for her while they sort out a care package. We were worried about how she would cope, but she is just really happy to be back home with her dog, Toffee.”
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