Improving hospital discharge and intermediate care for older people

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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.

Comments

david oliver

Position
visiting fellow,
Organisation
Kings fund
Comment date
13 October 2015
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

Paul Smith

Position
Director,
Organisation
Foundations
Comment date
14 October 2015
The next Home Improvement Agency conference will be held next April in Manchester - you're very welcome to return

Guy Patterson

Position
Community Champion/Research consultant,
Organisation
Help and Care
Comment date
21 October 2015
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).

Guy Patterson

Position
Community Champion/Research consultant,
Organisation
Help and Care
Comment date
21 October 2015
Right on cue...
http://www.theguardian.com/healthcare-network/2015/oct/15/community-services-must-speak-out-future-nhs?CMP=new_1194&CMP=

Caroline Walker

Position
community matron,
Organisation
east cheshire
Comment date
18 November 2015
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....

Karen Holmes

Position
Student Nurse,
Organisation
Bournemouth University
Comment date
16 January 2016
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.

Rob Halhead

Position
COO,
Organisation
Docobo Ltd
Comment date
18 February 2016
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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