New care pathways for frail older people can cut the amount of time they spend in hospital and long term care by better integrating services, writes Richard Newland
At any time, in any hospital, more than seven in 10 bed days are taken by patients who arrive as emergency admissions. Among these long staying emergency admissions (two weeks or more), four-fifths will be aged over 65. To put it another way: just a tenth of hospital patients account for 55 per cent of acute bed days overall.
Why are frail, elderly people spending so much time in hospital? It is widely recognised that for much of this time, older people are not in hospital for any clinical benefit, but due to delays in arranging the social care or community services they need before moving out.
HSJ’s Commission on Hopsital Care for Frail Older People
Older people are too often not getting the kind of care that NHS staff would wish for their own parents.
On 19 November HSJ’s first ever commission will publish its final report on how to tackle the most pressing issue facing the NHS.
The scale of the problem is enormous and impacts on the whole health system. The King’s Fund estimated that if this inappropriate bed use was effectively addressed, 7,000 fewer acute beds would be needed nationally.
Accordingly, its report, Older people and emergency bed use, found that in areas with well developed integrated services for older people, use of acute beds by older patients is lower than other areas. Hospital readmission rates for the elderly are also lower and patient experience evaluation better.
With strong integration of services, it is possible to stop the revolving doors, whereby older people come into hospital because it is the only place where the support they need is immediately available. While there may not be a quick fix, there are ways to make sure processes run smoother.
CHS Healthcare introduced a hospital discharge service at Lancashire Teaching Hospitals Foundation Trust in 2012. It has since been shortlisted for the HSJ Awards 2014 – for acute sector innovation – and has now been widely implemented in 17 other NHS acute trusts.
In the traditional scenario, those with the most severe needs are assessed as needing 24 hour care in a nursing home. The patient will also need a continuing healthcare assessment.
‘We are aware of areas of the country where patients become stuck in discharge to assess for months’
So the patient waits in hospital for these assessments to take place. The patient’s family will be asked to find a nursing home – something many families find overwhelming, some to the extent that they disengage with the process altogether.
The time taken from fit for discharge to leaving hospital, known as delayed transfer of care, can be many weeks or even months.
The experience for the patient and family is poor – the family often feels unsupported and under pressure to find a nursing home.
By assessing the patient while in acute care, the assessment takes place at a time when the patient is likely to be at a physical and cognitive low point and thus there is no alternative to a move from hospital straight to long term care.
A better way of managing this cohort is that as soon as the patient is fit for discharge from an acute bed, he or she should be transferred to a discharge to assess bed (a block or spot purchased nursing home bed). This transfer should take place no less than 48 hours after the patient is fit for discharge.
The nursing assessment in hospital should be carried out quickly, within 48 hours of the patient coming into discharge to assess.
The patient then spends a specified period – usually 14 days – in the discharge to assess bed. It is vital that at this point, there is a clear focus on what needs to be arranged and in place for the patient to move to the next step.
Shifting the delay
We are aware of areas of the country where patients become stuck in discharge to assess for months; the delay is simply displaced from one part of the system to another.
‘The patient is given the best opportunity to recover sufficiently to return to their home with a package of care’
At the end of the 14 days, the patient may need to have the full decision support tool to judge whether they are entitled to receive continuing healthcare funding or funded nursing care.
At the same time, the patient may be judged to be regaining physical and cognitive skills and therefore a further period of rehabilitation may follow.
This pathway ensures that the patient is given the best opportunity to recover sufficiently to return to their home with a package of care.
This may not be possible and 24 hour care may be a necessity. However, we regularly see patients on this pathway return to their own homes following focused rehabilitation. If the same patient was assessed in hospital, this opportunity would have been lost as they would have moved straight into a nursing home.
This pathway also allows for more effective working with the patient’s family; if a nursing home is required, there is more time for the family to adjust to this and make all the necessary arrangements.
The pathway also affords the opportunity for family to plan for and be present at key assessments.
The same principles apply to patients with moderate needs. This patient cohort is also at risk of either a long stay in hospital or moving straight from hospital into long term care.
‘Individuals receiving a six week reablement programme were able to reduce their home care hours by 41 per cent’
They are the cohort likely to benefit most from a well managed, large scale reablement programme. This involves the block purchase of care home beds, with physiotherapy and occupational health services attached to those beds.
Patients move from hospital into reablement for 14 to 28 days. Each patient should have a case worker who ensures assessments are carried out at agreed times and that services such as physiotherapy and occupational therapy are in place.
A social worker assessment takes place at the end of the reablement period, with the majority returning home supported by a package of care, while a few will need a residential or nursing home placement.
Patients with the mildest needs should have reablement services delivered in their own home by community services. While the benefits of regaining key life skills for independent living are clear from the patient’s perspective, they can also be measured in terms of the health system.
For example, in Edinburgh, people receiving a six week reablement programme were able to reduce their home care hours by 41 per cent.
Patients defined as having relatively mild needs can be at high risk of hospital readmission within 30 days. A model developed to identify patients at greatest risk of readmission cites deprivation, for example, as a major predictor.
‘We can avoid high delayed transfer of care rates and patients moving straight into long term care’
A clear pathway for these patients with reablement in place will help to reduce the risk of readmission and reduce dependence on paid for care.
There are five key principles behind the elderly frail care pathways:
- to minimise hospital stay and promote independence;
- for care to be provided at home wherever possible;
- to reduce long term care packages;
- to avoid making decisions about long term care while patients are in hospital; and
- at the point of being fit for discharge, patients can be defined as having mild, moderate or severe needs and should follow pathways according to this definition.
The CHS elderly frail care pathways show it is possible to avoid two major issues faced by hospitals: high delayed transfer of care rates and patients moving from acute care straight into long term care.
We can improve on what we offer to older frail patients by making clear at all stages in each pathway what the benefit is for the patient and what everyone – the patient, family, professionals – are seeking to achieve.
Dr Richard Newland is chief executive of CHS Healthcare