Reducing readmissions by improving care on discharge

When East Kent Hospitals embarked on a project to reduce hospital readmissions for older people, they thought it would be all about improving the quality of handover information. But after spending time following patients in the community, they realised the problem was actually a lack of specialist support once patients left hospital.

They went on to develop a multiagency approach to supporting older people after they are discharged from hospital, which has reduced readmissions by 38%.

Helping patients feel safe and supported after discharge

In 2011, East Kent Hospitals University NHS Foundation Trust began a two year project to address their high readmission rate for older people, as part of the Health Foundation’s Safer Clinical Systems programme.

Their project set out to improve the quality of handover for older people on the urgent care pathway at William Harvey Hospital, working specifically with people being discharged back into care homes. 

‘When an older person is discharged from hospital, they may feel vulnerable to have lost that reassuring contact with medical professionals’, explains Programme Manager Michelle Amourdedieu. ‘They may not really understand their medication. After a few days, their condition may start to deteriorate due to stress, and then they end up back in A&E. Readmission to hospital can be traumatic and also presents a massive risk. Older people can be susceptible to infections, or have comorbidities, so hospital is not always the healthiest place for them.’

‘This is part of a bigger Trust-wide commitment to reduce harm events by 10% annually,’ explains Helen Goodwin, Deputy Director of Risk, Governance and Patient Safety at the Trust. ‘The UK Trigger Tool classes all readmissions within 30 days as a harm event trigger. We wanted to improve communication during the transfer of care, to ensure that every patient could feel safe and supported after being discharged, thereby reducing harm.’

Getting to the root of the problem

The project began with a six month diagnostic phase. ‘We went out into the community to see exactly what was happening to older patients upon discharge,’ says Michelle. ‘We followed patients out of hospital and then back in on readmission, to gain a picture of the crisis points that led them back to A&E.

‘We quickly realised we could have the best discharge process in the country, but without some form of specialist support, vulnerable patients could be readmitted because there was no one to continue the care in the community.’

The team took their findings to the Clinical Commissioning Group who agreed to commission a community matron and consultant geriatrician to help meet this gap in care. They then introduced a range of interventions which connected up the community matron services, GPs and care homes and required organisations and teams to work together.

This included introducing a ‘comprehensive geriatric assessment’, a multidimensional handover process designed to assess an elderly patient’s functional ability, physical and mental health, and situation at home. Importantly it identifies any potential challenges and risks to them at the time of discharge, and considers how these can be managed. 

Building partnerships for change

‘Building trust was crucial’, says Michelle. ‘We held training days for Ashford’s 19 care homes, and I worked in homes as a health care assistant to increase buy-in from staff. The majority of hospital readmissions were happening after 5pm, so we extended matron hours to 8pm, and created a 24 hour on-call information service.’ 

Now, when an older person is discharged, they are referred to a community matron, who carries out a full assessment within 48 hours. An anticipatory care plan is formed, which outlines:

• a reconciled problems list
• physical status
• details of care structures in place
• an advanced care plan with end of life preferences
• lead clinical contact details
• a process for escalation in case of deterioration
• medicines reconciliation
• clear follow up processes.

The community matron works with the care home to deliver the plan. Any concerns are passed on to the consultant geriatrician who visits the patient within a week. 

Enabling choice and reducing harm

These collective working interventions have reduced readmissions by 38% and have been very positively received.

‘I see it as an enabling initiative, helping older people stay in their place of choice,’ says Michelle. ‘If they want to be in hospital then the geriatrician will enable that. But many don’t, they just want to be listened to.’

The service has now been fully commissioned, and has won a number of awards, including an HSJ award for Efficiency in Community Service Redesign.

‘When planning a project like this, you think you can predict where your key pinch points are, but the diagnostic phase helps you realise there are other factors. The anticipatory care plan for example, is something that care home providers can actually use, so that everyone understands the ceiling of treatment, and patients aren’t forced into a cycle of readmission-discharge-readmission-discharge’, says Helen.