community hospitals:

The east Cornwall community resource bed management project, a joint venture between Cornwall Healthcare trust and Cornwall social services, has now been operational for six months. The aim of the project was to achieve optimum use of the four east Cornwall community hospitals - St Barnabas in Saltash, Launceston General at Launceston, and Passmore Edwards and Lamellion hospitals at Liskeard - following health secretary Frank Dobson's decision in 1998 that they should remain open.1 The hospitals have a total of 89 beds.

The project aimed to facilitate earlier transfer of Cornish patients from Plymouth Acute Hospitals trust and Plymouth Community Services Hospitals trust, and successful discharge from the four community hospitals.

This involved identifying adult inpatients from Cornwall at Derriford and Mount Gould hospitals and the Royal Eye Infirmary. These are the acute district general hospitals in Plymouth that serve east Cornwall's 92,000 population.

A district nursing sister was appointed to the post of community resource facilitator, to identify patients suitable for care at a community hospital and facilitate their smooth transfer, and a specialist social worker was appointed to facilitate earlier discharge from the four community hospitals.

The health authority funded the project with£20,000 from winter pressures money for a three-month initial trial period between January and March. This period was statistically audited and evaluated. The scheme was then extended for a further three months. The project covered adult patients admitted to the acute hospitals, excluding psychiatric patients, attenders at accident and emergency, and day case surgery patients.

It relied on health and social services working together in partnership to provide integrated care, as outlined in the Partnership in Action discussion document.2

The community resource facilitator had contact with 556 inpatients during the trial period. Of these, 188 were transferred to an east Cornwall community hospital, 252 were discharged home, 34 died in hospital, 72 were transferred to another provider such as a community hospital outside east Cornwall, another acute hospital, hospice, nursing or residential home. Ten patients were still inpatients at the end of the audit period. No contacts were with patients at the Royal Eye Infirmary.

Table 1 shows an increase of 62 patients transferring to an east Cornwall community hospital from the acute trust in this three-month period, compared with 1998 statistics.

Table 2 illustrates overall average bed occupancy statistics for the community hospitals during the project period, compared with January to March 1998. At three of the hospitals, occupancy statistics for 1999 are the same or greater than in 1998. The role of the community resource facilitator in actively seeking patients suitable for care at the community hospitals led to this increase and greater utilisation of the community hospitals' resources.

Length of stay

Average length of stay statistics for Lamellion Hospital, the largest of the four with 33 beds, fell from 36.4 days in 1998 to 25.3 days in the study period. But at the other three hospitals it rose slightly.

Where length of stay in a community hospital increased, we believe this to be directly related to the hospital receiving patients at an earlier stage in their care. The specialist social worker had contact with 105 community hospital inpatients from Cornwall during the three months of the project.

The main group of patients were those with complex care needs. A variety of approaches were used to facilitate discharge (see table 3). Forty-five per cent of patients were discharged home with increased care packages. Forty-nine per cent of patients assessed by the specialist social worker required long-term or permanent care placements.

Sixteen per cent paid for their placement, 31 per cent required permanent nursing home placements and only 2 per cent went to residential care, indicating the very dependent nature of the patients whose discharges were being planned.

The specialist social worker was able to divert4 per cent of patients from the community hospitals via the temporary respite route, which gave the patients enough rehabilitation time to recuperate and return home.

Discharges from all four community hospitals appeared to follow a pattern. The complexity and dependency of the patients with whom the specialist social worker was involved was high.

During the three months of the project the specialist social worker took 105 referrals. Nurses in the community hospitals made these by telephone and face-to-face contact at weekly meetings. Speedier referrals for complex patients led to shorter hospital stays for some patients and enabled 57 more patients to transfer to a community hospital during the three-month trial period.

Care planning

The specialist social worker completed assessments and paperwork for 21 permanent care placements. Eighteen of these were for nursing care, only one was for residential care and two were for short-term respite care. These figures highlight the dependency of the patient group being cared for.

Of these assessments, 97 per cent were completed within two working days, and the rest within five working days. These figures underline the benefits of a social worker concentrating solely on community hospital discharges and transfers.

Twenty-seven patients with complex needs were able to return to their own homes on discharge from a community hospital with increased care packages. Without this period of increased support at home most of these patients would have required residential care.

GP access to beds

The project gave rise to a dilemma over GPs' access to beds in the community hospitals. If the community resource facilitator transferred patients and filled all the community hospital beds, then local GPs were not able to admit their patients.

Two approaches were taken. If the admission was not urgent the patient waited at home and was admitted to the next available community hospital bed. If the admission was urgent the patient was admitted to the acute hospital.

These patients were not viewed as inappropriate admissions for the acute unit, because if a patient was too ill to wait for a community hospital bed to become free then they were ill enough to be admitted to the acute hospital.

Conclusions

The community hospitals were sent a questionnaire to establish their opinions on the project and all wished for the specialist social worker to become permanent.

The project proved its worth to patients and the acute and community hospitals over its first three months. But we feel that a longer trial period would have been appropriate in order to compare 1998 and 1999 statistics.

The results of the first three-month trial were replicated in the following three months, and the audit is continuing. Greater numbers of appropriate patients continue to be transferred to the east Cornwall hospitals.

The benefits of joint working are clearly illustrated. There has been increased contact between Plymouth Acute Hospitals trust and Plymouth Community Services trust in neighbouring Devon, Cornwall Healthcare trust and Cornwall social services. Collaboration between all these agencies has led to improved patient management in both the acute and community hospitals settings, with best use made of the community resources in east Cornwall.

The project made a presentation to the east Cornwall primary care group enlisting its support, and a further three months' funding was allocated from the HA. The project has been extended to January 2000.

REFERENCES

1 Latham M. Dobson's choice: the hospitals will be saved. Cornish Guardian, 13-20 August 1998.

2 Department of Health. Partnership in Action - new opportunities for joint working between health and social services. DoH, 1998.

Jackie Shacklady is community resource facilitator and district nurse, Cornwall Healthcare trust. Maggie Browne isspecialist social worker, Cornwall social services.

Key points

A joint health and social services trial initiative to facilitate transfers from acute hospitals to four community hospitals in east Cornwall has increased placements.

Discharge planning from the community hospitals has also been improved with the appointment of a specialist social worker.

Staff involved believe the project has improved communicationbetween agencies.