Horizon Scanning – initiatives impacting on delayed transfers of care

Modern acute hospitals are designed for patients who have acute medical needs, and have, therefore, focussed their attention on supporting these needs. An increasing issue for these hospitals are patients having to stay in hospital beds for longer than is clinically required. 

These non-acute patients run the risk of acquiring hospital-born infections, and may decondition due to lack of appropriate physiotherapy for example. In addition, they prevent other patients from being treated, leading to increases in waiting lists.

When clinically appropriate, it is far better for patients to be treated closer to home, as their care can be tuned more closely to their needs.  So what are the best ways to maximise the number of patients who can be treated in this way, and therefore minimise the number who remain in hospital unnecessarily?

We have recently been working to look at what organisations are doing to help impact delayed transfers of care. A DTOC occurs when a patient is ready to leave hospital, but is unable to do so, and is, therefore, still occupying a bed. DTOCs are multifactorial so no single intervention will provide overall success. This makes a coordinated approach across multiple areas the most likely to achieve reductions.

Broadly speaking, it is possible to think about initiatives aiming to discharge patients sooner, initiatives aiming to avoid admissions (and hence potential DTOCs) altogether, and initiatives aimed at improving hospital flow of patients to ensure patients do not need to stay longer than medically required for their needs.

This paper focusses on these areas, as well as touching upon the new models of care vanguards which are trialling many new mechanisms across multiple areas of interest. This paper, therefore, does not focus on reducing delays that occur within the hospital (such as waits for diagnostics) although some of these interventions would affect them.

If you have an interest in this field, what is included below is a simple starting point for research. It is not an exhaustive list, some of these examples will overlap with others, and the field continuously evolves. Please check, research and decide whether the benefits you are seeking can be achieved through these mechanisms.

Discharging Patients Sooner:

	How does it work?	Examples to investigate
1. Supporting housing placement and step downs	This intervention is generally about supporting out of hospital placements through spot purchasing nursing home beds or through providing ”extra care housing” to provide rehabilitation and reablement and thus enable discharges from hospital to long term care.	Kings fund paper: Making best use of the Better Care Fund, Jan 2014 My Home Support – end of life allowing 9/10 to die in a place of their choosing, St. Giles Hospice with Bromford Social Enterprise (housing support) Health into the home (Elderly Mentally Infirm, frail and elderly and long term conditions), Midland Heart Health begins at home, provides advice, support, and housing referrals. Family Mosaic, £862k savings
2. Information driven decision making	Using information to monitor “real” patient flow through the health and social care system rather than the expected flow. This is likely to allow insights to be developed and better decision making by staff.	This is about the Council focussing on service user flow (real world flow vs theoretical flow) to identify gaps in knowledge and provision; and info sharing for better decision making using SHREWD – Single Health Resilience Early Warning Database, Kent County Council ASC
3. Information and advice to patients	Better informed patients and care givers should make for simpler discharging and potentially avoid admissions. This route provides information, help and advice to patients, typically older patients and their care givers potentially during in-home visits.	Older persons info directory – link to 1400 services hosted by Age UK Lambeth, Southwark and Lambeth Older persons advisory service (OPAL) to help stay independent for longer, Epsom and St Helier NHST Comprehensive Geriatric Assessment, Occupational Therapy and Care Assessor doing assessments in the home, Epsom and St Helier NHST
4. Dementia focus	This is a proactive case management model for discharging patients with dementia involving care givers in addition to patients. A specialist dementia occupational therapist is the single point of contact throughout the process.	My discharge – this is about support for discharging patients with dementia: LoS down 1.9 days, 34 per cent of permanent placement risk patients discharged to home, 26 per cent reduction in accident and emergency re-attendances, readmit avoidances, significant residential care savings (potentially £1.5m), Royal Free
5. Supporting outside the hospital	Often home circumstances mean it is not safe to discharge patients leading to a DTOC. This approach is about working with social services, the third sector and voluntary organisations to make changes at home during a hospital stay to enable successful discharges home, which should also reduce the readmission risk from falls, for example. A clear cause and effect for this intervention is difficult to show.	Swale staying put – basic changes to homes, Swale Manchester Care and Repair Making patient homes warmer and safer with emergency shopping (readmits reduced due to reducing in-home risk), Manchester Aster living support – visiting patients in hospital, to plan changes to home – move beds, assemble flat packs, repair trip hazards, check benefits if stopped, food in fridge, gas and electricity still connected? Also referring on for long term help, Aster
6. Changing hospital pathways or tariffs	The LTC Year of Care Commissioning programme is focussed on integrated care support for long term conditions. It is accompanied by tariff changes (capitated budgets) and has been recently introduced by the Department of Health. In Luton, the creation of integrated discharge teams have had impactful results in reducing DTOCs. Separately to this hospitals have been developing discharge to assess (D2A) and reablement wards to support timely and safe discharges.	The Long Term Conditions Year of Care Commissioning Programme, Department of Health Integrated Discharge Team for residents of Luton – 100 strong team of Social Workers, NHS Discharge Managers Discharge Officers and Administrators and Cambridge Community Services Liaison Sisters, co-located within the Discharge Hub at Luton and Dunstable Hospital, Luton Borough Council. Development of reablement units – “ward D47”, Sandwell and West Birmingham City hospital Discharge to assess, Warwickshire Therapy-led D2A, 3 week pilot, 12 patients saved 27 Occupied Bed Days (OBDs), University of Southampton
7. Leveraging the specialists	This is about exploring innovative tools such as “refer to pharmacy” for bespoke community pharmacist appointments, and utilising the skillset of the pharmacist to reduce DTOCs and support out of hospital medicine delivery.	Involving pharmacists to help tackle DTOCs, “Refer to pharmacy” East Lancs NHST Pharmacy solutions – such as chemo at home (can be safely flexed to alleviate DTOC), Sheffield Children’s Hospital NHSFT

Whilst the primary mechanism for reducing DTOCs remains looking at ways to discharge sooner, or to avoid the reasons why a discharge cannot safely occur; avoiding unnecessary admissions can also reduce DTOCs. Elderly patients can often experience reduced mobility as a result of staying in a hospital bed. If the original admission could have been safely avoided, it reduces the risk of the patient deconditioning and would thus avoid some of the causes of DTOCs. The following initiatives are all focussed on avoiding these original admissions.

Avoiding admissions (and therefore potential DTOCs)

	How does it work?	Examples to investigate
8. Specialist assessments in the Emergency Department	By involving a consultant geriatrician upon patient arrival at the hospital, consistent assessments on patient risk (vs the baseline condition of the patient) can be made. This can avoid many unnecessary admissions.	ED assessments by elderly care specialist (consultant geriatrician led), Clinical Interventions in Ageing. 2014; 9: 2033–2043. Published online 2014 Nov 24. doi:  10.2147/CIA.S29662
9. Falls rapid response team	Working with the ambulance provider on a rapid response falls service avoids admissions and nursing home placements (and DTOCs)	Working with ambulance provider to avoid unnecessary admissions (A&E callers) for falls, Nottingham
10. Streaming non-acute patients to better settings	This approach looks to book GP appointments from the A&E on behalf of the patient, and thus avoid a hospital A&E stay and potential admission.	Employing a “deflector” organising GP appointments @ A&E to steer away non-acute patients, Salford Royal FT

DTOCs can also be reduced through effective use of clinical specialists and more effective and timely decision making within the hospital.

Initiatives to improve hospital flow (reduce unexpected DTOCs) 

	How does it work?	Examples to investigate
11. Using the correct allied health professional rehab model	By involving the correct allied health professions at the front of the hospital (eg A&E) and for neuro-rehabilitation, DTOCS can be reduced as care can be aligned to current patient needs, with out of hospital care decisions made earlier.	Using the correct allied health professional rehab model to support Neurorehabilitation – NHS England, pan London DTOC review  The AHP workforce is critical to front door rehabilitative interventions, NHS England pan London DTOC review
12. Using Comprehensive Geriatric Assessments	Recent meta-studies have identified that a Comprehensive Geriatric Assessment ward with early discharge planning enables care focussed on geriatric needs and improves outcomes.	Comprehensive Geriatric Assessment ward with Early Discharge Planning, Meta analysis suggests patients will be: More likely to be alive and in their own homes at 12 months Less likely to be living in residential care Less likely to die or suffer deterioration More likely to experience improved cognition BMJ 2011; 343 doi: (Published 27 October 2011)
13. Daily senior clinical reviews and discharge planning	By having senior clinicians review patient progress on a daily basis discharges can be planned in advance and the necessary care and equipment sourced to reduce DTOCs.	Daily senior clinical review to progress care and plan for discharge, A simple guide to the care act and delayed transfers of care (DTOC)

The final area to explore are the new models of care vanguards happening across the country. This needs a paper to itself, however as a starting point the integrated primary and acute care systems looks to improve clinical decision making which would help DTOC rates.

New models of care vanguards

	How does it work?	Examples to investigate
14. New models of care vanguards	By integrating primary and acute care systems more rapid and accurate decision making can be made based on a more complete history of the patient. Other new models of care vanguards would also add significant value in reducing DTOCs and should be investigated.	Integrated primary and acute care systems the PACS model – The PACS model of care joins up GP, hospital, community and mental health services. In principle through improving the way GPs, hospitals, community and mental health services work together the delays in transfers of care can be reduced.

There is a wealth of material and examples available to support the reduction of DTOCs. It is a developing field with many examples being published on a regular basis. For example, the use of leading edge technologies for patient flow optimisation (eg at Johns Hopkins Hospital) should have a significant impact on DTOCs, through optimising patient flow decision making.

As with any intervention, form should follow function, which in turn should come from a thorough understanding of the issues. Having a clear and data driven understanding of the causes for DTOCs in any particular location allows for cross-system buy-in for the potential interventions required. Interventions should always be tuned to suit the local situation. 

DTOCs do not help patients who are waiting to leave the hospital. They may not be receiving care specifically tuned to their needs (as they are in the wrong clinical setting) which may have an impact on its quality.  Extended stays in hospital can have a deconditioning effect on patients which results in increased rehabilitation/reablement requirements, or patients who could have gone home needing residential/ nursing homes.

These patients could also be nearing their end of life. One example I encountered was of a patient who stayed in hospital 12 days longer than was necessary due to the difficulty in arranging in-home support. Subsequently 10 days after they were discharged they passed away. Over half of their last 22 days of life were in a hospital when they should have been at home with family.

Clearly, DTOCs need to be reduced, it represents the right thing to do for the patient, it allows the acute hospitals to focus on the sicker patients, and by streaming patients to the right setting at the right time it helps to optimise the running costs of the health and social care system.

The ideas and interventions covered in this paper will not meet every local need. This paper will hopefully provide a stimulus to thinking and further investigation about what more local areas can do, and what fresh approaches they might consider.

Duncan Harper is consulting manager at GE Healthcare Finnamore