The Future Hospital Commission: An opportunity to develop best practice around multiple morbidity?
Amit Arora is a consultant physician in care of older people and Chair of the England Council of the BGS.
The Future Hospital Commission report from the RCP has made many recommendations. It recognizes that most patients who attend hospitals do not just have a single medical condition. It highlights the need for some specialists but also more generalists. It also specifically mentions the benefits of Comprehensive Geriatric Assessment and the need for continued care in the community.
One of the challenges in optimising hospital care for frail older people is recognising that the majority of care actually takes place outside of secondary care. When older people stay longer than they should in hospital – whether as a consequence of delays in discharge, arranging care packages or acquiring and treating admission-related complications – this represents an unwelcome interruption in the continuity of care. Older patients can experience reduced function and mobility following an acute hospitalization, due to lack of timely and effective therapy services. This can prolong their recovery, and increase length of stay and in many instances cause further deterioration.
The report calls for seamless care without the physical or professional barriers or boundaries of acute hospitals and community settings. Many geriatricians have been advocating this for some time now and, more recently, have led the way in delivering care across the primary and secondary care interface.
The BGS and our local CCG are taking part in the Department of Health’s (DH) Year of Care and Recovery, Rehabilitation and Reablement funding model projects. The funding model has been developed through the QIPP LTC work stream to support health and social care teams in integrating care in a more sustainable way by aligning funding with people’s needs.
The model, which is is not mandated, has been developed using evidence and best practice and will be tested by the early implementer sites. The model will evolve over time with this testing phase informing future developments. It is important to realize that this project is not the same as personalized budgets but will give insight into the total spend on a group of patients with defined comorbidities.
This is a response to data which demonstrates the majority of patients in hospitals to be over 65 and living with multiple and complex health problems, which are also frequently associated with frailty and dementia. This is going to continue to be the case in the working life of most practicing physicians.
Important within the Year of Care and RRR projects is the consideration of a set-point within an admission when funding will divert from acute care provider to another provider. This potentially could overcome some of the challenges around community providers saying that they are inadequately resourced to receive patients from acute hospitals. If it is done correctly the funds will follow, or perhaps even precede, the patient. One of the challenges to the project is specifying the set-point at the right time within a patient’s stay when the funds can be transferred or Liberated, the L point.
However, it appears that with the current model, data collected about single organ pathologies including stroke, diabetes, cardiac failure and COPD, may underestimate the importance of frailty and co-pathology in determining minimum required length of stay. At the moment, YOC is working with data collected from discharge summaries, which are known to fail to capture all co-morbidities. This could potentially limit our understanding of what is happening at both an individual patient and population level. Fortunately, the BGS is amongst a number of stakeholder organisations working closely with the DH to help better understand these data.
We hope that, as part of this process, there will be an opportunity to develop a Best Practice Tariff for multiple morbidity and frailty, which will incorporate comprehensive geriatric assessment for all hospitalized and community dwelling patients.