As part of its involvement in the Health Foundation’s Flow Cost Quality programme, Sheffield Teaching Hospitals NHS Foundation Trust has overhauled the emergency care pathway for frail older patients. It has set up a Frailty Unit specifically for this group of patients and is testing an innovative discharge process, where patients leave hospital as soon as they are medically fit to have their support needs assessed at home.
Examining the current system
The conventional approach to discharging frail older people requires the patient to complete a series of ward-based assessments, involving tasks such as making a cup of tea and using the stairs, to identify what kinds of home support they will need. The patient is only discharged from hospital once all of the appropriate support resources are in place. Examples of support that may need to be arranged include visits from a carer, or equipment such as walking aids or a hospital-style bed.
Tom Downes, consultant physician and geriatrician, and the Trust’s Clinical Lead for Quality Improvement, explains the shortcomings of this approach: ‘Ward-based discharge assessments are quite time-intensive and once the patient is medically fit to leave hospital, it can take significant time to get their home support in place.
‘We analysed the notes for some very long-stay patients and found that they were spending much longer in hospital than their consultant felt was necessary from a clinical point of view. Not only was this a financial concern for the hospital, but our data also showed a worrying relationship between the time it was taking for patients to flow through the system and the potential for harm.’
Adopting the patient’s perspective
A multidisciplinary team, representing all the roles involved in caring for frail older patients, used patient stories and data to explore the problems in the standard discharge system, and to identify solutions to test.
‘When we put ourselves in the patient’s shoes, it became clear that the hospital ward is not the best place to see how someone gets on in their own kitchen, bathroom or bedroom – the best place to observe this is in their home,’ says Tom.
The team started running tests of a ‘discharge to assess’ approach, where patients are discharged once they are medically fit and have their support needs assessed on arrival at home by members of the community intermediate care and social care teams. This enables them to access the right level of home care and support in real-time.
In 2012, the Frailty Unit saw a 34% increase in patients being discharged on the day of their admission or the following day, with no increase in the proportion of patients readmitted to hospital.
Testing the new approach has produced interesting insights into patient experience. ‘We started to see that patients can perform quite poorly on ward-based assessments, but much better in assessments at home. This is especially true for patients with dementia,’ comments Tom.
He describes the impact of the new discharge model on one patient’s care experience: ‘This patient went home the day after he was ready for discharge – the one day delay was because his wife was unwell – and following his home assessment, was provided with a hospital-style bed and visited by carers three times a day. Under the conventional system, his team assessed he would have been in hospital for a further 12 days. We conservatively estimated that for these 12 days, his home care package cost around £2,000 less than the equivalent care in hospital. More importantly, he spent this time where he wanted to be – with his wife.’
The Sheffield team is continuing to develop the discharge to assess model, to lay the groundwork for it to become standard practice on the Frailty Unit and further across the hospital. One area they’re focusing on is how to build capacity and capability for home assessments to take place whenever they’re needed and wherever the patient lives in the city.
Tom says they’re also exploring the link between discharging patients efficiently and avoiding emergency situations arising. ‘We think there’s exciting potential for using the same type of capacity and capability to help GPs to manage the needs of frail older patients earlier in their illness, thus avoiding emergencies from occurring and the need to be admitted to hospital.’
If you would like further details about specific areas of this project, please email Tom Downes: firstname.lastname@example.org