Better Transfers of Care for Older People – how to improve transitions of care

Dr Olivier Gaillemin trained in Geriatric Medicine and now works as a consultant physician in Acute Medicine at Salford Royal Foundation Trust. He has developed a Frailty Unit embedded within the Acute Medical Unit. He sat on the NICE guideline development group for NG27 – Transitions of care for adults with Health and Social Care needs – as well as on the committee for the associated NICE Quality Standard QS 136. He attended the King’s Fund conference as a speaker.

On the day of the launch of their report on STPs, the King’s Fund hosted an event on how to improve transitions of care for older people admitted and being discharged from hospital. In these times of very real stress to the systems in which we work, when too often we seem to fail those vulnerable people we are all invested and motivated in supporting, it is easy to become despondent.

We may feel that without significant increase in monies and “capacity”, there is little we can do as individuals or teams to improve matters. However, the day made it clear that positive outcomes were being had, driven by teams working across organisational boundaries with patients and with a person-centred focus. Successes were celebrated and very practical examples shared. Most obviously, it was apparent that changes to language and approach to service design were afoot with the patient and carer voice coming to the fore. Is the traditional culture of health and social care changing?

In his introductory remarks, Richard Humphries, assistant director of Policy at the Kings Fund, set the tone as he alerted speakers and audience members that positivity was the order of the day.

The elephant in the room, namely Delayed Transfers of Care (DTOCs), was immediately tackled by Ashley McDougall of the National Audit Office with some simple and effective graphs and numbers. Whilst constrained funding and the rise in DTOCs are seemingly occurring in unison, the correlation of the two is not evident across all local authorities. DTOCs were falling in some whilst rising in others despite the same curtailment in social care funding. This is perhaps not surprising given a minority third of DTOCs are down to social service factors exclusively. And variation in reliably delivering established best practice is large, both within and between organisations. An example was the availability of Frailty Units delivering Comprehensive Geriatric Assessment (CGA) seven days a week.

Grainne Siggins, London ADASS lead for Health and Integrated Care, defended the much-maligned Better Care Fund as having enabled new relationships across organisational boundaries putting in place the building blocks for future collaboration. Good professional relationships matter if we are to better co-ordinate systems to ensure care on the ground is and feels more seamless.

Throughout the day I was struck by the repeated message that a person-centred approach gives professionals a common focus to improve linking-up of services and share organisational “risks”.

We were reminded of the personal consequences of not heeding the patient voice by Neil Tester and Rosalind Pearce from Healthwatch, who presented the findings of their report “Safely Home”. The personal stories highlighted what we all intuitively recognise as of most importance: for people to be treated with dignity and respect; to ensure that people’s needs were considered as a whole and not simply their presenting symptoms; to involve people in their own discharge planning and to inform them as to where and to whom to turn to for help post discharge.

Communication in all its forms and communication early during the process of admission was the recurring theme. This may be pre-admission, but certainly on admission with regards to liaising with key formal and informal carers, community care-coordinators, housing even, for effective discharge planning.

Much of this, which appears to be common sense, is now evidenced and recommended by NICE guidance.

I was privileged to have been invited to present the NICE / SCIE Guideline and NICE Quality Standard relevant to the topic. Key again is that information relevant to an individual’s care transfers from the community to the admitting team; that CGA is commenced at the point of admission for those with evidence of Frailty; that a named discharge coordinator is identified to promote communication and drive discharge planning; and most importantly that family and carers, along with the person themselves, are involved in the discharge planning process and have their discharge plan available to them prior to transfer from hospital. Solutions to the above will vary per locality. I would suggest a Quality Improvement approach is the most effective way to harness staff expertise and knowledge and develop and embed best practice. I have certainly found this approach fruitful in developing our own service in Salford.

With parallel as well as plenary sessions, there were many great examples of service improvement to be had and I would encourage you to go to the King’s Fund website where all presentations are available to view. Coffee breaks were abuzz with people sharing top tips and invites to visit and demonstrate each other’s work.

A highlight for me was Sutton’s “Red Bag” project. Viccie Nelson and Dr Raphael Rogans-Watson presented a really simple idea, as ever progressed with energy and purpose. Patients from Residential Homes being admitted to hospital were transferred with their “Red Bag”, a very visual, physical object which contained important personal belongings such as glasses, dentures and hearing aids along with Care Plans and other vital information from the Community. The Hospital staff would make reference to this and further attach the discharge plan to the Red Bag at point of transfer home. Furthermore, the service change included the Care Home manager attending the patient hospital bedside within 48hours of admission to link in with the hospital team. The outcome was that patients admitted with a Red Bag had a four day reduction in length of stay relative to those without and reduced subsequent Emergency Department attendances.

A team from Fife led by Allied Health Professional staff and supported by a Geriatrician and Nurse Consultant, proactively identified Frailty at the “front end” to appropriately deliver early multi-disciplinary team assessment. Evaluation identified positive patient and “System flow” outcomes.

Brighton and Hove focused on simplification of systems: reducing variation in practice, duplication and delays. A “Home First” approach minimised the chance of “over prescription” of support post hospital assessment.

You cannot disagree with Liz Sargeant OBE (Clinical Lead for Integration, Emergency Care Improvement Programme) and her pertinent, straight-talking advice: the answer to making better use of the resources in a system lies with the staff on the shop floor. They have the system knowledge and motivation to improve patient care. With space and support positive changes will happen.

Time to tackle:

  • Attitude
  • Behaviour
  • Culture

Time to wake up to the Sound of Music. Do ré me. Do see me. Have the patient in mind at all times and the solutions will come. Commit to an Expected Date of Discharge, use the SAFER Patient Flow Bundle, think Home First…How many of us would choose to spend days on end in hospital when that time was not adding to our recovery and indeed was potentially harming us?

The day concluded with a panel discussion chaired by Professor David Oliver in his own inimitable style (somehow managing to weave Blind Date into the proceedings).

I was left feeling that whilst the Health and Social Care systems are clearly under phenomenal stress with complex system changes remaining a challenge, there is also much that can be done, now, by front line staff in adopting and developing best practice.

Great examples were demonstrated. Practical, useful guidance abounds. Communication will always remain key and can be hugely enhanced without waiting for an all singing, all dancing, IT system. When the people we are here to treat and support are kept in mind throughout and engaged in the development of services, much can yet be achieved with the resources currently to hand.

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