A team from East Kent Hospitals University NHS Foundation Trust have improved their transfer of care processes for frail and elderly care home residents. By providing better discharge information and new community-based support they have transformed follow-up care for this vulnerable patient group and reduced unnecessary hospital readmissions.

Unnecessary time in hospital can be very harmful to frail older patients, exposing them to other risks, such as hospital acquired infections, and often leading to extended stays away from home.

Since 2011 a team from East Kent Hospitals University NHS Foundation Trust have been working on a project to improve transfer of care processes for frail care home residents admitted to hospital for unscheduled care. Readmission rates within 30 days of discharge were particularly high for this vulnerable group.

It was thought that poor communication between professionals when patients were discharged was leading to ineffective follow-up care, making it more likely for patients to deteriorate and need to be readmitted.

A systematic approach to identifying the problem

One of eight healthcare organisations participating in the Health Foundation’s Safer Clinical Systems programme, the team took a systems approach to improvement. Providing a structured way of looking at an unreliable system, this involves mapping clinical pathways, understanding external influences and then proactively identifying risks and testing solutions.

Management lead, Helen Goodwin, explains the benefits of this approach:

‘The “diagnostics phase” makes sure you step back and map out the actual care process. You think you know where the problems are but it turns out you often don’t. We had assumed we would need to improve the handover info we provided to GPs through our electronic discharge system. We didn’t realise that the problem actually lay with a lack of communication between acute services and the care homes.

‘As soon as we started talking to care homes it became evident they were receiving little or no information when patients were discharged, particularly if the GP wasn’t around over the weekend. Information they did receive was also written in very medical language, making it hard to understand.’

The diagnostic phase also identified a lack of specialist support for patients in the community, both at discharge and during times of crisis, which often resulted in emergency readmission to hospital.

Forming partnerships to find solutions

The team held meetings with the care homes and worked closely with them and emergency care staff to develop a new communications tool: the Anticipatory Care Plan. This is written in simple and non-medical language and is specifically designed to communicate with care homes when patients are discharged back into their care.

They also approached the local clinical commissioning group (CCG) in Ashford who agreed to fund a new community team, consisting of a community matron and a geriatrician. This team now case-manages patients within the care home, acting as the first point of contact when a patient is discharged from hospital. The matron assesses all discharged patients within 48 hours, ensuring continuity of care and appropriate follow-up. This has significantly helped to reduce the number of readmissions to hospital within the first week of discharge.

The geriatrician supports the matron to develop anticipatory care plans (112Kb) [doc-file] for patients preparing for end of life, while also providing specialist support to care home staff. The community team are available on call whenever a crisis arises that would normally result in an A&E admission. Already familiar with the patient, they can advise on their general condition and whether or not they are deteriorating.

Evaluating the impact

Through these interventions the Trust has seen a clear reduction in unnecessary readmissions to hospital within 30 days, and has implemented a safer process for the handover of care for this vulnerable patient group.

‘We’re still aiming for our stretching target of a 50% reduction in readmission rates’, says Helen. ‘We did achieve this one month, but there’s still work to do. Overall we’re now seeing a reduction of around 30% across the board, which we’re delighted with’.

Another positive output from the project has been the level of engagement achieved from all stakeholders. Strong relationships are now in place between the Trust and care home providers. ‘We now all feel safe to share information about both good and bad practice and use it as an opportunity to learn’, says Helen.

The team were recognised for all their hard work at the HSJ Efficiency Awards last month, where they were winners of the award for ‘efficiency in community service redesign’.

The Trust now hopes to introduce a similar partnership approach with three other local CCGs. Future work is also planned which will look at reducing readmission rates for frail older patients living in their own homes.

Further reading

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