Hospital at Home Admission: A Crucial Opportunity for Future Care Planning

Introduction

Future care planning (FCP) is indispensable in managing frailty and/or advanced disease, requiring comprehensive discussion of prognosis and treatment options. By articulating what is important to the individual, a personalised future care plan promotes autonomy and dignity. The Recommended Summary Plan for Emergency Care and Treatment (RESPECT) process facilitates FCP and had already been implemented within some areas of our NHS Trust. This quality improvement initiative aimed to promote RESPECT implementation within the hospital at home service to improve FCP for older adults. 

Methods

A retrospective analysis of case notes was performed for all patients admitted to the hospital at home service during three one-week periods pre-initiative to identify evidence of completion of the following (prior or during admission to hospital at home):

1. FCP discussion
2. RESPECT form 
3. ‘Do not attempt cardiopulmonary resuscitation’ form 

After engagement with a range of stakeholders, a test of change was formulated where resident doctors robustly identified patients that might benefit from the RESPECT process during the daily MDT. Resident doctors or consultants completed the RESPECT form after discussion with the patient or their representative. Data was collected post-implementation for comparison. 

Results

Continuous data collection showed a sustained increase in RESPECT documentation from 0 to 13% of patients and improved communication of FCP with community care providers. A specific case study demonstrates that RESPECT form completion empowered the ambulance service not to convey a patient to hospital, as per his documented wish to remain at home. 

Conclusion

Hospital at home admissions are opportunities for FCP for patients living with frailty and/or advanced disease, particularly pre-emptive decisions concerning hospital transfer in the case of clinical deterioration. A proactive RESPECT strategy results in completion of high-quality personalised FCP for selected older people in a home setting and improves communication with other healthcare providers.