The right intervention, at the right time, in the right place…
Stephanie Robinson is a higher specialist trainee in geriatric and general internal medicine currently working as a clinical lecturer in Geriatric Medicine at NUI Galway. Her research interest are service planning for older adults, dementia, vitamin D, coeliac disease, ageism, incontinence, nursing home care standards and stroke.
The right intervention, at the right time, in the right place… How Harrogate District Foundation Trust therapists from the community and in-patient wards are tackling the national bed crisis: piloting a Supported Discharge Service.
The pressure is on in Harrogate – the population of over 60s is 26.5% compared to 22.4% nationally. By 2030 the district’s over 65 population is predicted to increase by 15,000 people. One of the Trust’s strategic aims for the next five years is to integrate acute, community and social care to allow patients to be treated closer to home, or at home and reduce reliance on acute beds. It is understood that therapy assessments completed in a patient’s own home are a more accurate reflection of their capabilities than those completed in the hospital environment. Based on the Discharge to Assess model, the concept that the hospital is often not the most appropriate place for patients of any age to remain is not a new one. This is especially true in regard to frail older people, who do not bounce back quickly after infections and for whom, waiting on a hospital ward for assessments to identify where and when they can be discharged, can lead to deconditioning and worse patient outcomes.
The Trust’s community and inpatient therapists are in the throes of managing the ageing population by using innovative models to influence the discharge process, promote positive changes in practice and improve patient outcomes. The #endPJparalysis campaign, which was run by community and inpatient therapists and involved the wider MDT to ‘get up, get dressed, get moving’ is still under pinning therapy clinical reasoning. Alongside this campaign, July 2017 saw the start of the Supported Discharge Service (SDS) pilot with the aim of supporting patients to return to their usual place of residence as soon as they were medically fit and to maximise their independence, thus avoiding or reducing extended length of stays and deconditioning in the over 65 patient cohort.
Our SDS team is made up of occupational therapists, physiotherapists, support workers and, for a short time, nurses. Each member operates generically but brings a diverse range of skills and experiences to the team. There is a mixture of both hospital and community staff. There has absolutely been a steep learning curve for all members and the team have upskilled each other through close integrated working and communication. There has been shared learning on hospital discharge processes and also on medications, continence, skin integrity and pressure relief. Having access to the community therapists’ computer-based notes system within the hospital has led to information sharing with ward therapists regarding home environments and previous therapy input with current inpatients. This has not only promoted cross boundary working but supported the ward therapists in reducing duplication of their decision making and assessments. The team have consistently shown that using this model has improved patient flow and has discharged on average an extra two patients a day.
The promotion of a different way of working has been welcomed by the wards who have become accustomed to dealing with discharge delays. The Discharge to Assess model has been met at times with discussions around ‘how do you know they are safe to go home if you only assess them at home’ from patients, relatives and the wider multi-disciplinary team (MDT). Despite this feedback ward staff, patients and their relatives who have come into contact with SDS have been overwhelmingly positive about the impact the team has had on supporting discharges. It would be expected that the team has also reduced the reliance on referrals to the community teams. As ordinarily the ward therapists may have referred onto them for bathing assessments, outdoor mobility practice, assessment and provision of internal and external grabrails, this allows for continuity of care and a streamlined service. The SDS team is in a unique position of interacting with acute, community, social care and voluntary sectors crossing some previously very traditional boundaries.
It’s a work in progress to develop strong working relationships with all members of the MDT, but we’re striving towards the Discharge to Assess model becoming the normal way of assessing the many patients who come through our hospital doors.