No one can keep admitting sick people to a hospital if those whose treatment is complete and are ready to go home are not leaving the wards.
Blocked beds – also known as ‘delayed transfers of care’ (DTOCS for short) – cost the NHS dearly and cause longer queues in the hospital’s emergency (or A&E) department.
At Great Western Hospital they have started a pilot of a system called Home to Assess and it is already having an impact on the number of empty beds GWH has available on any one day.
At present it – as Chief Executive Nerissa Vaughan told the GWH Board – ‘”Small stuff’. But the results in terms of freed-up beds were, she said, good: “It’s the first time ever we’ve had positive information about DTOCs”
When I went to meet the leaders of the Home to Assess team, GWH was on a high state of alert – that means the hospital was FULL. During October GWH was running with bed occupancy at 104 per cent – with extra beds brought into use. The level of bed occupancy for safe and efficient treatment of patients is considered to be 85 per cent.
For those fit enough after medical treatment, Home to Assess moves the assessment process for the care they will need, from hospital to home.
To explain how it works I met the three people leading the scheme: Senior Occupational Therapist Emily Hussey, Jill Kick working in Discharge Services and Alison Koster, with a nursing background and now GWH’s Associate Director of Patient Flow.
And sustained flow through the hospital is what this is all about: it is crucial not just to free up beds for those who need to be admitted from the emergency department, but also for the safety of frail and vulnerable patients.
These three health professionals know well that staying in hospital too long can be bad news. The old can very quickly become institutionalised so losing independence, they can pick up infections and they can have falls: “Family members,” says Emily, “really came on board – once they had it explained that hospital is not the best place for their relative.”
The Home to Assess (H2A) scheme turns the usual process upside down: instead of waiting in hospital while they are assessed for the type of care they need and an appropriate care package is assembled, some patients who are deemed fit enough will go home and be assessed in their homes. But no one is sent home who will not be able to manage between care calls.
“Hospital”, Alison Koster told Marlborough.News, “is quite a false environment for assessment for what care and help they need at home.” It is one thing to ask a patient while they are lying in a hospital bed and hoping to leave if they can make themselves a cup of tea at home – and tick the box. It is so much better to see them making a cup of tea in their own home.
If, after medical treatment, a patient needs a wheeled Zimmer frame, they may find it easy and safe to use on the hospital’s flat and uncarpeted floors. Get them home and they may well fall as they try to negotiate carpets, rugs, narrow doors and hearths.
Patients are chosen for H2A with reference to the NHS’ exacting codes of fitness and they are discussed with the clinical specialists treating the patients and at daily multi-disciplinary meetings. Individual needs and the wishes of relatives are taken into account.
When each H2A patient arrives home they will have someone there to make sure they are all right for the night. Next morning the assessment starts – with a “burst of support” to complete their assessment within their first 72 hours at home. It is a staff intensive scheme.
They will be seen first by an occupational therapist, followed by nurses and sometimes a physiotherapist. The occupational therapists do the functional assessment – making sure a patient can cope with personal care, is safely mobile and can carry out domestic tasks. This is the key element in determining a patient’s care needs.
The H2A team at GWH is small at present – two occupational therapists, a physiotherapist and intermediary care nurses from the community team. The current pilot scheme only concerns patients from Swindon.
Emily Hussey and Jill Kick are new members of GWH’s staff. In October they transferred to GWH from the social enterprise organisation SEQOL when GWH became caretaker for Swindon’s community healthcare services. GWH takes over the full SEQOL contract in February.
Emily and Jill’s close involvement with this scheme shows the advantages that more integrated community healthcare services will bring to GWH and its patients.
This team have many plans for the future – more use of tele-care and tele-health (remote monitoring of vital signs) and the introduction of single-handed equipment – aids for the old and disabled which only need one person to handle patients safely.
This H2A scheme is not unique – it has been used by a hospital in Aintree and a similar scheme is used by Salisbury Hospital. At GWH the scheme was set-up as part of the hospital’s plans to combat ‘winter pressures’ and was funded by the Swindon Clinical Commissioning Group.
It started on November 14 and has so far involved 32 patients – all but one of them continue to function well at home (one needed ‘reablement support’.) In the new year, the team’s aim is to use the scheme for five patients a day five days a week.
Delayed discharges are at crisis point. In October GWH lost the equivalent of 805 bed days due to delayed discharges. This was less than the September figure but was a 42 per cent increase on October 2015. The November figures are expected to be more sertious still.
Beds are in demand: GWH had to cope with 165 more emergency admissions in October than in September – and that was an 8.7 per cent increase on October 2015.
The hospital’s plan to reach required government target for number of people coming to their emergency department and being seen, treated, admitted or discharged in under four hours, relies on the number of DTOCs being halved. So the success of H2A is very important.