Home guard

The need to respond to increasing emergency admissions, particularly of elderly patients, has stimulated a number of intermediate care schemes across the country.

These vary in approach, but there seems to be widespread support from professional staff and health managers for 'hospital at home'-type schemes and rapid-response services, which facilitate the prompt discharge of elderly people from hospital.

The North Essex health and social services collaborative care pilot project - run by Essex Rivers Healthcare trust in partnership with Essex social services - takes this concept one stage further. Patients are discharged home as soon as they are medically fit, with a home-care plan providing rehabilitation and an assessment of continuing needs in the patient's home.

A planned discharge date is required from the consultant within 48 hours of admission so that preparations can be made for a home plan to begin as soon as possible.

The project was piloted at Colchester General Hospital, a 429-bed hospital with 50 beds for acute care of elderly people.

Generic home-care support workers were recruited and trained by health and social services staff to carry out rehabilitative care. A team of occupational therapists, physiotherapists, social workers and district nurses provides professional supervision and support, acting as key workers for each patient.

The patient works with the support worker, gradually taking more responsibility for carrying out daily living tasks for themselves. The patient's goals and the timescales for these are agreed between the patient and their key worker at the beginning of the programme.

The project funds the first four weeks of this integrated health and social care package, with social services picking it up at week four.

A formal review is carried out in the third week after discharge, with a community care assessment identifying long-term care needs.

The team supports about 32 patients at home at any one time and there are approximately eight discharges and eight admissions a week.

Results service

Patients and carers are generally satisfied with the service. The trust's delayed discharges have been reduced from a high of 120 a week before the collaborative care project to an average of 50 a week (although this is also partly due to a change in the data collection process). An evaluation of the scheme carried out in February 1999, which followed up 154 patients, showed that 41 per cent required no continuing care after week four, 32 per cent required support from social services, 15 per cent were receiving collaborative care, 7 per cent were re-admitted to hospital and 5 per cent had died.

The long-term cost of community care is significantly less than expected on discharge home. Patients are discharged home with an average of 28 hours of home care a week. At week four, following rehabilitation, this has fallen to an average of three hours' home care a week.

The project was considered a success in north Essex and as a result has been extended in Essex Rivers Healthcare trust to cover all of north-east Essex. The project has also been successfully implemented with similar results in mid-Essex at Broomfield Hospital, and more recently in the west of the county.

The pilot project demonstrated that patient throughput could be increased with collaborative care. There was an expectation that this would result in 'spare' bed capacity which could be used for elective surgery.

As collaborative care is extended in the trust, discharge and admission processes are being more tightly managed so that best use can be made of the newly released bed capacity.

Collaborative care is not a one-off project but a new process for managing admissions and discharges. Its success depends on changing professional behaviour across the trust. Future plans include extending collaborative care so that it is accessible to GPs and community nurses as a way of preventing hospital admission.

The health authority and social services have commissioned a full internal evaluation, but while the results are encouraging, the research is not yet conclusive. There are plans for an independent evaluation by Eastern region's research and development unit.

Deborah Klee is strategic development manager primary care, Essex Rivers Healthcare trust.