Improving hospital discharge and intermediate care for older people

Acute hospitals in England are under unbelievable pressure right now and winter is on its way. Even though we have a rapidly ageing population and an increasing number of people living with complex long-term conditions, frailty or dementia, we have lost hospital beds at pace over the past three decades.

Against this backdrop, hospitals are experiencing record levels of emergency activity and delayed transfers of care. The recent high-profile Care Quality Commission report on Addenbrooke’s Hospital highlighted a high number of acute beds occupied by patients medically fit to leave. A recent audit by NHS Benchmarking showed that while only 5 per cent of people aged over 65 who are admitted to hospital stay for more than 21 days, that 5 per cent accounts for more than 40 per cent of all bed days.

There’s pressure on hospitals from emergency readmissions too – emergency readmissions within 28 days of leaving hospital run at around 15 per cent for people over 65 and overall numbers are rising. Improving support for older people at home – either to prevent hospital admission (or readmission) or to facilitate discharge when they are ready to leave hospital – is key to patient flow and ultimately to delivering the four-hour A&E waiting times target.

Behind the system issues and the growing workforce and funding pressures in acute hospitals, there is a real human story.

Healthwatch England’s recent report, Safely home, described in harrowing detail the personal stories of patients and their families who felt that their discharge from hospital was unsupported or premature. It also described patients marooned in acute beds unable to move on. This echoes previous reports from Age UK, the National Institute for Health Research and the Royal Voluntary Service.

It’s a stressful environment for clinicians and operational managers, who are under constant pressure to prevent hospital admissions, discharge patients sooner and get them home when capacity and responsiveness in primary and community health services is lacking. Social care has also suffered, with an estimated 40 per cent cut in revenue since 2010, and with many people receiving no statutory care despite their needs being classed as ‘substantial’. In addition, few carers for older people get formal support. 

It can be too easy for acute hospitals to place all the ‘blame’ on those services and not do enough to put their own house in order and work more collaboratively across organisational boundaries. It’s also too easy for those services to throw blame back onto hospitals when people cannot be discharged because of a lack of support within the hospital to facilitate it. We need to move away from these behaviours.

Hospital inpatients are increasingly old. Many are living with frailty and most have a degree of functional impairment – either in mobility or other activities of daily living. Many such patients leave hospital less mobile and independent than when they were admitted – making rehabilitation after acute illness and injury a core business not just for hospitals but also for their partners in ‘step-down’ intermediate care services. These services also have the potential to provide ‘step-up’ (admission prevention) care, for early supported discharge from the hospital front door or wards.

The National Intermediate Care Audit has shown insufficient capacity or responsiveness in these step-up/step-down services, though they work well for people who use them who often report good person-centred outcomes.

Against this backdrop, The King’s Fund is hosting two small interactive workshops.

The first, on 15 December, will focus on older people leaving hospital – including how to improve the quality of hospital discharge and patient experience, prevent readmission and reduce delays. We’ll be hearing speakers from Healthwatch England, the Royal Voluntary Service and Derby Teaching Hospitals NHS Foundation Trust, and there will be plenty of time for sharing ideas and experience with other delegates.  

On 9 February, we are devoting a day to improving intermediate care services. Speakers include NHS Benchmarking, South Warwickshire NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS Trust. We hope you can make it.

We won’t solve the very pressing problems facing the NHS unless we crack these wicked problems. What’s good for the system – joined-up care and a focus on maintaining independence – reflects what older people and their families want to see too.

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Comments

#544964 Lord Best
Chair, APPG Housing and Care for Older People

Don't forget housing: it can cause the hospital admissions (accidents, illness) and readmissions (because the cause remains); or can prevent the problems (if safe, warm,accessible) and cut health and (domiciliary and residential) care costs.
Care and Repair/Home Improvement Agencies need the support of Health and Well-being Boards.

#544973 David Oliver
Visiting Fellow
The Kings Fund

Lord Best is quite correct to point out the key importance of housing in this story. He and colleagues such as Jeremy Porteous have done fantastic work in the all parliamentary housing group. Not only in discussing age friendly housing and communities but the key role of care and repair charities and home improvement agencies.
We specifically mentioned the importance of housing in "making health and care systems fit for an ageing population " at the Fund in 2014

For those interested can i suggest following these links to the Housing Learning and Improvement Network (or "LIN") and its library of resources

http://www.housinglin.org.uk/

http://www.housinglin.org.uk/Topics/type/

Also just one example of how care and repair and adaptations can help people get back home in this report

http://www.housinglin.org.uk/_library/Resources/Housing/OtherOrganisatio...

I am sure i wont be repeating my performance as the after dinner speaker for the Home Improvement and Handypersons' agency Conference in Stratford 3 years ago as i used up all my best gags in one evening

Keep up the good work

David Oliver

#544978 Chantal Harding
Social Worker
Integrated Community Services (ICS)

I work for ICS in Shropshire, a team of both health and social care workers who specialise in facilitating safe early hospital discharges by continuing therapy and care support in the patients home for a period of rehabilitation and assessment. We can ensure correct equipment is in place as well as care support and adjust this quickly to meet immediate need. We also provide Admission Avoidance - for example when an acute onset of UTI takes hold and a usually independent person requires care support due to confusion causing them to neglect themselves - we can provide care support and therapy/medical support whilst they get back on their feet - preventing admission to hospital.
It is something we are proud of in Shropshire and I am proud to be a part of.

#544979 David Oliver
visiting fellow
The Kings Fund

Thanks Chantal
That sounds like just the kind of model we could all learn from and the Kings Fund would be interested in knowing more about. Well done to you and local colleagues. Is it written up anywhere as a case study or blog or on a website about your services so we can share more widely? If not I will get you to write a 600 word blog for www.bgs.org.uk so we can share with our followers over at the BGS where I am current President

David

#544982 Helen Kelly

Housing providers can absolutely address these issues. I work for a housing and care provider which has in the last 2 years entered the health market to work in partnership with NHS Trusts to deliver intermediate care services providing both a step down service from acute beds to alleviate delayed discharges and a step up service from the community preventing acute admissions. Our reablement services have reduced the average lengths of stay for the frail elderly and reduced readmissions back into hospital through our links with community and voluntary services. The problem is that health are still reluctant to have conversations with housing because they are still unclear as to the benefits housing providers can bring unless they have evidence of cashable savings. CCGs need to step up to the plate and commission more intermediate care services and let housing providers in the health door!

#544983 David Oliver
Visiting Fellow
The Kings Fund

Dear Helen

I agree with you and have very much banged the drum for housing, and care and repair charities. However, Anchor were either reported or misguided in the Daily Mail in September that hospital doctors and nurses were hanging onto patients to keep beds full in order to generate tariff income. For those of us in those roles (as i very much am) every day is a struggle to find beds, to turn patients round in A&E and AMU and prevent admissions, to facilitate earlier discharge and to work on alternatives to hospital attendance. Hospital staff doent know much about the tariff, dont think about it much, many wouldnt recognise their finance director let alone have him or her pushing them to admit more patients or keep hold of them longer. And of course all the same issue exist in the devolved nations which have more beds and no tariff.

What is important to realise is that many many older patients in hospital who might be technically "medically fit for discharge" and able to be cared for somewhere else dont just "need TLC". They are often still well short of baseline mobility and functional independence and need active rehabilitation not just convalescence if they are to regain their independence. They also often have a range of ongoing medical problems, some of them potentially unstable. So they need skilled rehabilitation and access to proactive and reactive clinical support. The National Audit of Intermediate Care shows that such supprot can work and work well for people but that there isnt enough of it and it isnt responsive enough and too often its based around provider interests/skills and not individuals' needs.

I am agnostic about which organisation provides greater capacity and responsiveness in post acute support, rehab, transitional care, but it must have access to personal care, rehab and skilled clinical input if it is to meet peoples needs and it must be funded by someone. Given big cuts to social care provision and given that the intermediate care audit round 2015 shows if anything longer waits than last year, it may be a moot point who provides services so much as whether any of them are adequately funded or provided to deal with unmet need

Its also important that organisations from housing or voluntary sector who are also after a share of the business just the same as a conventional NHS community health provider are very up front about this in their pronouncements

David Oliver

#544995 Jo Doubleday
Occupational Therapist
Kent OT Consultancy Ltd

Occupational therapists play a major role in facilitating timely and safe hospital discharges and supporting people when they return home to live. We aim to prevent hospital re-admission, care home placements and informal carer breadown and enable people to improve their independence, safety, well being and quality of life.

I work in the community in a moving and handling team where everyday we follow up hospital discharge patients who return home needing double handed care packages which are becoming more difficult to source and is often a cause of delayed discharges. Often older people are admitted to hospital following a fall at home or with an acute illness and may spend many weeks being nursed in bed or chair bound and are discharged no longer able to walk.
This could change if:
1. More OTs and Physiotherspists are employed in hospitals to provide early intervention and rehabilitation which can help to reduce the number of hospital bed days.
2. More joined up working with OTs and Physios in the community to provide early follow up rehabilitation and enablement to improve independence and reduce the need of costly double and single handed care packages and hospital re-admissions.
3. Improve referral systems and the length of time it takes to work on complicated case management systems so more time is spent with patients.
4. More OTs and physios could provide falls prevention training and programmes to reduce falls. This is a severely neglected area of training for all staff working with people at risk of falling and particularly in care homes. 1 in 2 people over the age of 80 fall each year and the highest reason for hospital admission in the over 65s.

To summarise the government desperately needs to invest to save and employ essential therapy follow up care that people need in hospital and in the community to improve mobility, health, well being and independence and reduce hospital bed days and hospital admissions.

#544997 david oliver
Visiting Fellow
The Kings Fund

Dear Jo

I absolutely endorse all of this. My job would be impossible without the fantastic OT and PT colleagues i work with at the Royal Berks and in neighbouring community in reach teams and i have been a relentless advocate for the importance of the AHP workforce across acute and intermediate care services and not forgetting in reach into nursing and residential homes. You'll hear no argument from me. We have also organised two Kings Fund Conferences all about the key role of Allied Health Professionals - the second one coming up soon on 8th December. Let's hear it for AHPs

David

#545003 Shane
AHP
NI

Will videoconferencing facilities be available for either event?

#545005 Sharon Hudson
Palliative Care Lead Nurse
Heart of England Foundation Trust

I am hugely supportive of this approach which we are supporting within our Vanguard in Solihull. My question is, where does end of life care fit into this model? The frailties framework addresses the need for rehab and step up/down care to support discharge and admission prevention which is BRILLIANT but how about those that we recognise are dying? I sense we need to build an extra bit in... 'recognise dying?... then implement this bit.. which includes single point of access, coordinated hospice at home with single source funding and no CHC...'

30% of all hospital inpatients are likely to die in the next year. Half of us will still die in hospital. This is our time to build care at end of life into this brave new world.

#545006 david oliver
visiting fellow
Kings fund

To Sharon

I need no convincing. I do a huge amount of end of life care work and work very closely with palliative care. We devoted a whole section of "making health and care systems fit for an ageing population" to this subject, and I recently wrote in the BMJ and HSJ about the need for a concerted approach to this subject and to have a grown up public dialogue and face up to it. I just happened on this occasion to be writing a piece focussing on intermediate care and planned transitions from hospital in a more general sense and linked to a couple of workshops we will be doing. But I am on the same page as you about this issue and will speak to my colleagues at the Kings Fund regarding a bespoke conference or workshop on this issue.

Meanwhile for Shane in Northern Ireland, all the presentations from the AHP conference will be on line shortly afterwards in one form or another and we will be live tweeting and storifying

David

#545007 Paul Smith
Director
Foundations

The next Home Improvement Agency conference will be held next April in Manchester - you're very welcome to return

#545026 Guy Patterson
Community Champion/Research consultant
Help and Care

Awaiting further detail from Chantal, whose work in Shropshire sounds very much in line with my own thinking and activity to support small local teams, initiatives and projects to improve the level of community support and care offered to people leaving hospital - including their transport which is so often seen as no more than a means to an end, when in fact a well planned journey in the company of trained volunteers can be a key element in providing reassurance to people who may be anxious and disorientated.

Involving the community and voluntary sector in the organisation and co-ordination of hospital discharge does add an extra dimension of support, and also acts as a catalyst to integrating health and social care practice. It does not happen by accident, and takes time to develop into an established way of working, but it pays dividends - as I have seen in Dorset where a long-standing programme designed to help older people stay independent in their own homes (Partnerships for Older People - POPP).

#545028 Guy Patterson
Community Champion/Research consultant
Help and Care
#545151 Caroline Walker
community matron
east cheshire

Longing for moves to philosphies c.f. seperate teams. Palliative care, intermediate care, urgent social care and more. Unhelpful labels leading to muliple confusing potential solutions and delays. Empower the generalists, share the budgets, avoid the delays. The solution is often the same despite the label. Rapid access to quality care (and equipment) at home supported by local mdt. Often imposs to label as intermed or palliative care anyway for frail pts with uncertain recovery...does the label really matter? I think the actual care matters more....

#545647 Karen Holmes
Student Nurse
Bournemouth University

David,
I am currently a 3rd year student nurse at Bournemouth University and I am completing a literature review on integrated care for older people and the topic I have chosen in avoidance of admission into acute care. There are many models or integrated care that are currently being trialed across a number of 'developed' countries, an example of this can be seen in Bird et al (2007) integrated care facilitation for older patients with complex health care needs reduces hospital demand. The evidence that integrated care when utilised effectively reduces hospital usage in the first instance and then helps to reduce readmittence, improves patient experience and outcomes is I would say from my limited reading is strong. The main problem appears to be in the organisational structuring of the intergration, i.e who will fund it, along with professional attitudes not necessarily offering as much practical support as they could due to 'professional boundaries'. In my acknowledged limited experience I would say that if a patient can have their health managed effectively at home before a health crisis occurs that requires secondary care treatment then surely that is better for the patient for the secondary care budget and for the professionals providing the care. It is perhaps an incredibly simplistic view on things however sometimes the simplest solution is overlooked.
As an aside I would welcome anyone pointing me I. The right direction for more evidence on the effectiveness or ineffectiveness of integrated care.

#545806 Rob Halhead
COO
Docobo Ltd

Karen I might be able to help a little with 'pointing you'.

If you want to give me a call, office: 01372 459866 (I'll let the folks know to put you through).

Best wishes
Rob

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