MS Word download

Introduction  

Day Hospitals (DH) are out-patient healthcare facilities in which multi-professional assessment, treatment and rehabilitation is available on attendance for a full or part-day basis for older people in the community. [1, 2]

The BGS considers the GDH to be an important component of comprehensive services for older people. There is a wide variation of services provided throughout the country. Currently no national guidelines exist on the role of day hospitals.

The DH developed in the United Kingdom during the late 1950s and 1960s as part of the rapid changes that occurred in the care of frail older people. The main purpose of the DH is to prolong independent living by the specialist assessment and treatment of frail and disabled older people enabling them to remain in their own homes as well as having a favourable impact on impairment, disability and handicap. The past 50 years have seen many changes in the type of service provided. In addition to the traditional multi-disciplinary rehabilitation model for the frail older people, there now exists in many day hospitals a range of other services such as specialist clinics for patients with falls, or Parkinson’s disease, heart failure, Transient ischaemic episodes as well as rapid access clinics.

Day Hospitals have been demonstrated to be an effective service provider of comprehensive assessment of frail older people and rehabilitation by reducing the likelihood of death or poor outcomes. [2,3, 4,5,6,7].

Day Hospitals should play an active and effective role at the interface between primary and secondary care as part of the continuum of specialist health services for older people outside an acute hospital setting (see BGS good practice guide).

DHs have a particular role to play as part of a seamless intermediate care provision through provision of a comprehensive assessment

DHs have an important role in chronic disease management through their partnership with primary care. By regular review of at risk patients, exacerbations, disability and handicap and inappropriate admissions can be reduced by managing the condition, and avoiding iatrogenic disease.

Current Function

The BGS recommends that Day Hospitals should provide:

• Comprehensive assessment of frail older people. (see BGS good practice guide)
• Crisis intervention and sub-acute assessment with the possibility of preventing hospital admission or promoting subsequent early discharge.
• Integrated assessments of health and care needs, for example associated with decisions regarding institutional care placement or chronic disease management programmes in the community. (8)
• Treatment and rehabilitation, in particular for complex multi-faceted problems, (8) as part of community based rehabilitation and intermediate care.
• Specialist medical and nursing procedures.
• A venue for specialty clinics particularly where multi-disciplinary assessment is required. Examples such as falls clinics, movement disorder clinics, leg ulcer clinics, diabetic clinics, memory clinics, continence services and TIA clinics.
• Rapid access admission avoidance clinics.
• Health education for the third age.

The BGS recommends that older people attending the DH have:

• Immediate access to senior medical opinion at all times.
• Trained nursing staff with a nursing leader present in the DH at all times.
• Immediate access to social services provision.
• Immediate access to GH type investigations such as radiology and pathology.
• Daily support from allied health professionals services in particular physiotherapy and occupational therapy.
• Access to other professionals such as speech and language therapists, podiatry, surgical appliances etc.

The DH will most commonly be located in the DGH, where access to staff and comprehensive assessment is more easily delivered, although in some localities the DH may be more appropriately delivered in a large CH. Those DGH’s without a DH service should urgently review, in conjunction with their PCT’s, their ability to deliver the functions described above, in the light of the importance and current emphasis on the management of long-term diseases in the community.

Management

Medical management of all patients in the DH should be consultant led with regular multi- disciplinary team meetings to ensure patients attend on the basis of need and the ability to benefit.

Every day hospital should have a day hospital management group (or similar) which meets formally at least on a 2 monthly basis.

There should be adequate administrative support and an effective transport system.

Clinical Governance

The British Geriatrics Society in September 2000 produced three “screening indicators” for clinical governance for use as part of a comprehensive clinical governance approach in geriatric medicine. Two of these are of relevance to day hospital care. [9]

Patients seen as out-patients or day patients by an individual consultant or member of his or her team should have at least one recorded assessment of both their mental and functional states in the care records. Where clinically relevant (but not invariably) this will involve the use of a standardised measurement scale (e.g. abbreviated mental test or Barthel index or equivalent).

Functioning in the wider NHS

The increasing development of community based intermediate care teams can be seen as an opportunity to extend the evidence based advantages of a comprehensive assessment model in day Hospitals to the care of older people in the community. This would facilitate better case finding, better medical management of step up intermediate care patients and better coordination of care.

Future Day Hospitals may become part of a hospital without walls containing day surgery, out patient clinics, radiological and pathological investigations, advice centres, assessment rooms for therapists and integration with social services as well as links with community matrons in the management of chronic disease.(9)

Out of hours use could also be considered, in particularly with partnership with social services, education providers, voluntary and charitable organisations. Possible uses include day centre, keep fit and yoga classes, stroke clubs, Parkinson’s Disease Society group meeting and health education clubs.

References

1. Report of the Research Unit of the Royal College of Physicians and the British Geriatrics Society. Geriatric day hospitals; their role and guidelines for good practice. London: Royal College of Physicians, 1994.
2. Foster A, Young J, Landhouse P. Medical day hospital care for the elderly versus alternative from of care. Cochrane Database of Systematic Reviews. 2000.
3. Foster A, Young J, Landhouse P. Modern day hospital care for the elderly versus alternative form of care. Cochrane data base of Systemic reviews. 2000.
4. Brocklehurst JC, Tucker J. Progress in geriatric day care. London: King’s Fund, 1980.
5. Murdoch PS, Martin BJ. Geriatric Day Hospitals in Scotland: Current Provision and Practice. Health Bulletin 1997; 55: 221-224.
6. Smith RG, Davie JW, Murdoch PS. Geriatric Day Hospitals in Scotland: A Consensus View. Health Bulletin 1997; 55: 225-228.
7. Black D A. The geriatric day hospital. Age Ageing 2005 34; 427 – 429
8. Clinicians, Services and Commissioning Chronic Disease Management in the NHS. The need for co-ordinated management programmes. Report of a joint working party of the Royal College of Physicians of London, the Royal College of General Practitioners and the NHS Alliance. Royal College of Physicians of London, 2004.
9. British Geriatrics Society Good Practice Guide. 1.3 Standards of Medical Care for Older People- Expectations and Recommendations (Revised 2003) http://www.bgs.org.uk/Publications/Good Practice Guide/compend1-3htm

Acknowledgements

The BGS Policy Committee acknowledges Dr David Black who developed the first BGS policy document on Day Hospitals and assisted in reviewing and developing this revised document.

Jackie Morris
for the BGS Policy Committee