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Hospital Discharge

Super stranded patients

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By Gabrielle Silver

There is much discussion around so-called ‘super stranded patients’, however there is little acknowledgement that these patients can often be the result of insufficient communication between hospitals and families.

I was at a meeting at a large, well-performing trust recently and there was some discussion about an older man who had been in the hospital for over 120 days even though he had been well to leave many weeks earlier. The reason he was unable to leave was that he wanted to move into a care home which was compatible with his faith and that could also care for his specific mental health needs. There was only one care home nearby which met these criteria and unfortunately, there were no places available. As you can imagine, due to this care home’s unique provision, all their beds were taken and the wait for a place to become available was significant – hence why he had been in the hospital for over 120 days.

Being in hospital for this long is not good for anyone, particularly an older person. NHS Improvement has recorded that 35% of 70-year-old patients experience functional decline during hospital admission in comparison with their pre-illness baseline; for people over 90, this increases to 65%. The impact of an extended stay in hospital can’t be underestimated in terms of risk of further illness and physical or mental decline.

At CHS, we approach these complex situations differently. Every day we support hundreds of patients who have ongoing care needs at the point of discharge from hospital. Our priority is to help the patient leave hospital as soon as the MDT judge them to be ready and to go to a care setting which can best suit their needs, with a plan mapped out that may have a number of different stages. When a patient has very specific requirements, such as the one mentioned above, we would focus on honest and frequent communication with the family. We would confirm our understanding of their requirement for a specific home and commit to moving the patient when a place was available. We would, however, start to discuss and accompany them to see next best alternatives. We would explain what’s not right for him is a lengthy hospital stay where the basics of his faith cannot be attended to and his physical and emotional wellbeing are at risk of deterioration.

One of our strengths as an organisation is that we know local care homes, and this helps us understand where people will fit both clinically and culturally. In this specific case, it would likely be an interim solution whereby he moved to a local home which could provide appropriate care for his mental health and where a significant portion of residents are from his faith, and therefore the staff can cater to his pastoral needs.

Nurses and doctors are fantastic at dealing with patients and families, but they are also very busy people who are rightly focussed on the clinical needs of people in their care. We have dedicated teams who focus solely on family liaison and on understanding all the important elements of life pre-admission. We recognise these super stranded patients can be very challenging to manage but we know that it is only through multidisciplinary working, with the patient and family at the centre, that improvements can be made.

Finding the right care for someone with dementia

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Jo Wood, Hospital Discharge Care Advisor, CHS Healthcare, based at Medway Hospital

Half of the patients we organise care packages for have dementia. We support families to find the right care for a loved one and it’s important to find what’s right for that individual. If the person requiring care has dementia, our first action is to find out as much as possible about them and how they were before they were affected with dementia. You have to get a picture of someone as a person, not someone with a disease. For example, if someone was gregarious and had an active social life, then I would look at larger care homes that have all sorts of activities going on – from gardening, singing and dancing and even visits from zoo companies with meercats and sheep. If someone was less outgoing, then I would suggest a smaller home, with fewer group activities, where they could participate in one-to-one activities and spend time in their room, so they don’t feel overwhelmed by lots of people.

The Alzheimer’s Society has created The Butterfly Scheme and we use their assessment with the friends and family to find out all about the patient and what they did before the illness progressed. It’s all about finding the right care where they will be comfortable and as happy as possible.

I recently did a search for a home where a lady wanted to watch squirrels out of her window. I found one for her with big gardens, with squirrels, rabbits and birds!

Ideally, people are placed as close as possible to their loved ones, so they get regular visits, but the family will ultimately make the decision.

We will find three or four homes for a family to visit, and we will come along with them to support. When visiting a care home, I do advise people to look closely at the care that is being provided. Fancy fish tanks and chandeliers may look great, but who will be looking after their mother? At a care home, talk to the manager and ask lots of questions. When is the laundry done? Is there a visiting hairdresser and chiropodist? Do they have visits from a district nurse? How are they going to care for another condition like diabetes?

Some people prefer to be cared for in their own homes. We’ll work with them to make this happen and we’ll help them to develop a relationship with the carer and adapt accordingly. Some of our clients want to care for their loved ones in their own homes, which we can help with. Things change as the disease progresses, and we are there to review care needs as things change.

Of course, people can have good quality of life with early stage dementia and continue to do what they have always done – seeing friends, walking and watching sport for example. And later on, by organising care that suits them, they can still be listening to jazz, looking at their stamp collections and watching squirrels if that’s what makes them happy.

CHS Healthcare founder is named as finalist in prestigious business awards

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CHS Healthcare chief executive Dr Richard Newland has been selected as a finalist in prestigious EY Entrepreneur of the Year awards.

Dr Newland, who founded CHS Healthcare in 1995 while working as a Birmingham GP, is a Midlands finalist in the Sustained Excellence category. Though his work in general practice, Dr Newland recognised there was a lack of good quality advice and professional guidance for families making important care choices.

He used private finance to establish the company, based on advisers supporting families to find care and began with a single employee. Today, CHS Healthcare employs 350 people with services throughout the country, from London and the south coast up to the north-east and Cumbria.

CHS Healthcare is the leading independent provider of services to support the discharge of patients from hospitals, avoiding costly delays. The company also has the largest resource in continuing healthcare and complex care; delivering bespoke, specialist services to the NHS.

The EY Entrepreneur of the Year awards are now in their twentieth year and are widely recognised as a benchmark for recognising excellence in business.

Some of Britain’s best-known business figures are former EY Entrepreneur of the Year winners, including: Stelios Haji-Ioannou, who founded the low-cost airline easyJet; Dragon’s Den investor Peter Jones, who started-up Phones International Group; and Richard Reed, CBE, one of the founding partners of Innocent Drinks.

Joanna Santinon, EY Entrepreneur of the Year UK Leader, commented: “EY Entrepreneur of the Year was launched in the UK twenty years ago, to celebrate the engine room of the UK economy. Entrepreneurs not only create jobs and generate wealth, they also help to inspire other businesses, with their positivity, persistence and vision.”

Dr Newland is one of a group of Midlands finalists who will attend an awards ceremony on June 26, with the winners going on to a national judging process.

Beds Taken By “Super stranded” Patients Are Equivalent to Having 36 Acute Hospitals Out Of Action

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Up to 18,000 “super stranded” patients remain in hospital after being medically optimised for more than 21 days, NHS chief executive Simon Stevens has stated.

This is equivalent to the bed base of 36 acute hospitals being taken by patients who are not in need of acute care, but who are delayed for other reasons (choice delays, assessment delays, community services provision).

The figures were discussed during a recent appearance by Mr Stevens before the Commons’ Health and Social Care Committee.

Winter (2017/8) saw a focus on delayed hospital discharges with some qualified success. It is estimated the drive released 1,700 beds, although they were quickly filled by patients with flu and norovirus.

Discussions around planning for the next winter (2018/9) have again featured the issue of delayed discharges, with this time with an emphasis upon the “super stranded” patients, delayed by 21 days or more. Although most delays to discharge are typically less than 21 days, the ‘super stranded’ take up a disproportionately large proportion of hospital bed days due to their long length of stay.

It is understood that new plans might include incentives for social care providers to prioritise care packages for patients in the “super stranded” category.

Optimising the use of NHS England’s 128,000 bed base will be critical next winter as it is uncertain whether there is likely to be any significant cash injection or commitment to increasing the acute bed base.

What is the shortfall in capacity? NHS national leaders have recently suggested the service is at least 4,000 beds short of what is needed to meet A&E and bed occupancy targets. NHS Providers have stated the shortfall is much higher: 15,000 beds short (or 12 per cent of overall bed base).

But it was notable that after Mr Stevens’s committee appearance, subsequent NHSE briefings were heavily focused on optimising the existing bed capacity and particularly on super stranded patients. A spokesman told the Health Service Journal:

“As Simon Stevens told the [committee] last week, around 18,000 people currently in hospital have been ‘stuck’ there for more than 21 days. That’s the equivalent of 36 acute hospitals being ‘out of action’ because of delays getting patients out of beds.

“Building on recent success in reducing DTOC, the operational focus or the year ahead will now turn to reducing super stranded patient numbers in partnership with local community health providers and social care services.”

CHS Healthcare has worked in hospital discharge for 20 years and is currently commissioned to provide in-house hospital discharge services (including discharge to assess) in more than 30 hospitals across the country. We are commissioned by NHS Improvement to provide focused support in areas under particular pressure.

Dr Richard Newland, chief executive of CHS Healthcare “We recognise this concept of the ‘super stranded patient’; we regularly see these sorts of delays in hospitals where we work. When there are complex care needs, there will be multiple agencies involved and together with family choice, a myriad of actions required to achieve discharge.

“It is therefore very easy for delays to occur and when they do, two things are essential: there must be ‘ownership’ of the discharge; person centred care co-ordination of all the actions involved and focus on all causes of delay. Otherwise, it can become a case of ‘waiting for someone else to do something’. Equally, strong tracking and data is vital for visibility of all delayed patients and robust information to show the exact causes of the delays.”

Our hospital discharge service is commissioned by NHS Improvement

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We have been commissioned by NHS Improvement to provide hospital discharge services in Staffordshire.

NHS Improvement recognises the value of our work and expertise in supporting families, reducing choice delays and improving patient flow.

Dr Richard Newland, chief executive of CHS Healthcare, commented: “We are really delighted that our expertise in hospital discharge has been nationally recognised by NHS Improvement in this way.”

“We have shown NHS Improvement our services, with evidence of the impact we achieve, and we are very pleased to be commissioned as part of a national programme of strategic support for hospitals facing particular challenges.”

In additional to this nationally commissioned scheme, our services are locally commissioned throughout the country. We currently provide in-house discharge co-ordination in 30 hospitals from Cumbria, through the north-west, Midlands and London to the south coast.

We consistently achieve challenging key performance indicators: families are contacted on the same day as the referral is made, care home is chosen within two days of referral and transfer to community care is achieved within five days of referral.

NHS Improvement have commissioned our work in the University Hospitals of the North Midlands (UHNM). The scheme commenced in March, with a focus on Fast Track and self-funding patients.

In our other main area of expertise, continuing healthcare, our services are also centrally commissioned by NHS England.

We have been providing hospital discharge services for 20 years, with unique expertise and experience in this area. Our advisers, who work directly with families to focus on appropriate care choices, visits and decisions, are available during evenings and weekends. This is often more convenient with families and significantly reduces delays.

Our knowledge of the community-based care sector in each locality where we work and our strong relationships with care providers also means we can drive down causes of delay. The strength of our reporting and information management is also widely recognised.

Outstanding contribution to the care system – award for our service as part of hospital discharge team

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Tina Snowdon, CHS Healthcare Business Manager (south-east), said: “We are so proud of our team in Norfolk – they are a close knit, brilliantly optimistic and positive team who have done a great job from day one.

CHS Healthcare is part of the discharge team at the Norfolk and Norwich University Hospital Trust which has just been awarded for making an ‘Outstanding contribution to the Norfolk Care System’.

The work of the Integrated Discharge Team (IDT) was acknowledged in a staff awards ceremony highlighting outstanding achievements and efforts.

We started working at the Norfolk and Norwich University Hospital in April 2017. Initially, the team was commissioned to work with 20 families of self-funding patients each month, supporting them to choose a care home or arrange a package of care in their own home.

The service quickly embedded and worked so well it was extended to include continuing healthcare patients in a discharge to assess pathway (pathway 3). The total number of all patients and families supported rose to 40 per month.

Discharge to assess is acknowledged as best practice for discharge management, working on the principle that assessments should take place in a non-acute setting, ensuring the patient is a care setting that best meets their needs.

Both areas of work reduce delays to hospital discharge and improve patient flow, as well as enhancing the patient experience by providing much needed advice and support.

Tina Snowdon, CHS Healthcare Business Manager (south-east), said: “We are so proud of our team in Norfolk – they are a close knit, brilliantly optimistic and positive team who have done a great job from day one.

“We are also deeply appreciative of the support we have received from the Norfolk and Norwich University Hospital. From the start, we received fantastic support from the Trust in terms of communicating what we do and in terms of the wards making referrals to us.

“This partnership between ourselves and the hospital is at the heart of this success; as part of the IDT, it is really rewarding to know we are making an outstanding contribution to the health system and making a tangible difference for the patients and families using our service.”

In total, thirty-one individuals and 13 teams from the Norfolk and Norwich University Hospital and Cromer and District Hospital received awards at a ceremony on October 20.

Patients and colleagues have been able to nominate employees in 14 award categories, such as leadership, clinical teaching, patient care, research and lifetime achievement.

CHS Healthcare chief executive to judge Health Service Journal awards

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CHS Healthcare chief executive Dr Richard Newland has been invited to be a judge in the prestigious Health Service Journal Value Awards, 2018.

The HSJ Awards are widely recognised by the NHS as a showcase for best practice, with many hundreds of entries assessed by leading figures in the health and social care field.

Dr Newland has been invited to judge the category: improving value through innovative financial management and procurement.

The Value Awards focus not only on effectiveness and efficiency, but also on overall outcomes in all aspects of healthcare. Winners will be announced at a ceremony in Manchester in June 2018.

Dr Newland comments: “I was absolutely delighted to be invited to act as a judge in these awards. The high calibre and broad range of expertise within the judging panel underlines the way these awards are so very well regarded. There is strong representation from NHS leadership, strategy, third sector and areas of specialist expertise.

“In the current climate, these awards are especially relevant and applicable. The NHS is being tasked with achieving very tough financial targets without compromising quality and outcome.

“This process will highlight many examples where, despite these challenges, solutions have been found, through innovation, rigour and introducing new ways of working. I am delighted to be involved and look forward to assessing the entries.”

CHS Healthcare has long supported the HSJ Awards, having twice been commended and shortlisted for our hospital discharge services, with evidence showing our services reduce delays to discharge and achieve significant savings.

Utilising the stranded patient concept to improve patient flow

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By Dr Richard Newland, chief executive, CHS Healthcare

At a recent gathering of academics, NHS managers and strategists, a phrase that was repeated in many sessions was the “stranded patient”.

The concept is simple: define the proportion of beds in a hospital occupied by patients who have been there for seven days or more. Although some patients will have a severe illness or trauma that necessitates a hospital stay of more than seven days, many others will be in hospital for an excess of seven days because of unnecessary waits (typically an assessment, referral or availability of community based services). In other words, they are stranded in hospital because they are ‘waiting for something to happen’ rather than any medical need.

Like all good metrics, the stranded patient has a clear utility value. Applying it on a ward level, teams should identify any patient who is in hospital for more than seven days and consider:

  • Why does this patient need to remain in hospital?
  • What is being done and by whom to get this patient home?
  • What could have been done during the first few days of admission that may have prevented this patient from becoming stranded?

Answering and addressing these questions can be a useful tool in more actively understanding and improving patient flow. Reports from individual hospitals show teams are achieving six to ten per cent reductions hospital stays of more than seven days.

On a strategic level, hospital managers can calculate what percentage of patients are staying more than seven days as a proportion of overall patients. Although this will inevitably capture some patients who need to be in hospital for more than seven days, it is argued that this indicator (stranded patient as a proportion of all admissions) is a more meaningful reflection of patient flow than the ubiquitous DTOC.

Delayed transfers of care, measured from the point when a patient is fit for discharge but remains in hospital, produce a high number of cases where delays are caused by problems with services in the community the patient needs. This interface between acute and community care is enormously significant. But we need to acknowledge, measure, understand and improve problems with patient flow which occur within hospitals also. As one chief executive puts it: to look at DTOC alone is to only observe the tip of a very complicated hospital discharge iceberg.

CHS Healthcare has worked in hospital discharge for 20 years and today, we are commissioned to provide services in more than 25 hospitals from Cumbria to the south coast of England. Our experience chimes with many of the principles discussed with the stranded patient metric and improving patient flow. For example, we have seen how effective daily board rounds can be where there is a specific focus upon hospital discharge. The practice of each patient having an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CFD) are also effective tools for ensuing there is the process and mindset to actively plan for discharge from the moment a patient is admitted.

From experience we know, for example, that if a family needs to find and choose a care home before leaving hospital, this is a process which should be started at the earliest possible stage, in conjunction with medical treatment and care. From experience, we also know that services providing care and support at home are under great pressure in some areas; work to arrange home care packages, particularly if needs are high, should take place at the earliest possible stage. In other words, actively addressing two of the questions asked in the stranded patient metric and working always with the principles of right care, right place at the forefront of care planning.

A closer look at the OPEL guidelines: our services are EXACTLY what is recommended to mitigate against pressure

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Thanks to a winter of unprecedented pressure, the OPEL framework is becoming increasingly familiar, both within the NHS and beyond.

Published last October, the Operational Pressures Escalation Levels Framework was developed to establish a nationally consistent system for defining pressure on health and social care systems.

The idea is to have agreed criteria for interpreting pressure and clear mitigating actions to address that pressure at each stage.

Inevitably, media headlines have focused on individual trusts declaring OPEL level four, the highest state of pressure and escalation.

However, lesser publicised detail of the framework, particularly the mitigating factors for each level of escalation, provides a very valuable insight into what can be done when a health and social care system comes under pressure.

For example, when a system moves from OPEL 1 to OPEL 2, across all the mitigating actions, these themes stand out: prioritising discharge in clinical processes plus better co-ordination and communication between acute and community.

The guidance states: the acute trust must maximise rapid discharge of patients. At the same time, commissioners should expedite additional capacity in the community and independent sector, while community care should also maximise use of reablement/intermediate care beds.

This is precisely the interface where we work; we recognise the impact which can be achieved here, despite all the well-known challenges. For example, where we are commissioned to maximise discharge of patients by providing care co-ordination and family support, we are typically reducing DTOC (Delayed transfers of care) by 50 to 80 per cent, depending on trust’s benchmark before our service commenced.

Working effectively with the community health and social care sector, we reduce delays (for example, by supporting care homes to speed up hospital based assessments) and through our close and individual links with care providers, we do find capacity even in the most challenging areas.

Moving up from OPEL level two to three, again, there is a consistent emphasis in all parts of the system to expedite discharge by discharge. Again, the need to ensure care packages are arranged to facilitate discharge is described in the guidance several times. The guidance also states that domiciliary care packages should be increased for individuals in their own home to reduce the risk of those individuals needing an emergency hospital admission.

We work in 25 different hospitals across the country and frequently hear “there is no domiciliary care” resource in certain areas, or where an individual has very complex needs. In some areas, services are working with an automated system of care brokerage, while others are heavily reliant upon email based communications. Our teams speak with home care agencies on a daily basis; through these relationships, we build willingness to meet challenges and the ability to find solutions.

We would not seek to underestimate the challenge of domiciliary care capacity, particularly in some parts of the country. However we have shown, in many areas, that better communication and co-ordination does have a real impact in terms of finding capacity and solutions.

Even on the highest OPEL level four, where the overall emphasis is upon emergency measures, there remains a focus on discharge and community capacity. Community services are tasked with ensuring all available capacity is identified and board rounds are recommended to achieve “quick wins” and better flow. We have been involved in board rounds, tasked specifically with expediting discharge and recognise how this step can have a very significant impact.

In other words – there are factors in an escalation in pressure which are very difficult to control. But there are mitigating factors at each level; there are things which health and social care systems CAN do. And the same theme appears in the mitigating factors in all four escalation levels: expedite hospital discharges by a number of measures applied across the whole health and social system – use board rounds, prioritise discharge, good communication with community providers, consistent and rigorously seek capacity, even in challenging areas. These are all interfaces where we work: we can support patient flow and we do so on a daily basis in NHS hospitals from the south coast to the north of England.

NHS Improvement visit CHS Healthcare hospital discharge service in Burton

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We were pleased to welcome a delegation from NHS Improvement to visit our hospital discharge service for Burton Hospitals NHS Foundation Trust.

We have been running a hospital discharge service in Burton since October 2014, supporting hospital discharge by co-ordinating home care packages and helping families to choose care homes.

The delegation from NHS Improvement was comprised of Luke Edwards, Director of Sector Development, Andrew Edmunds: Community and Mental Health Implementation Lead and Nadia Yegorova-Johnstone, Economic Adviser, Provider Efficiency.

This visit from NHS Improvement in December 2016 follows Lord Carter’s visit to another of our hospital discharge schemes in Surrey, which took place a month earlier.

At Burton Hospital, the NHS Improvement Team were shown an audit carried out by Julie Wainwright, co-ordinator at Burton, focusing on patients with the longest length of stays and the reasons for these delays.

“The audit showed the wide range of causes and complexity of arranging discharge for patients with the longest delays,” explained Julie, who discussed the audit with the NHS Improvement Team.

“Notably, just finding all the relevant information for each individual was challenging, with many different professional teams involved across different services and information held in different places. Just building a ‘full picture’ for each individual was challenging and time-consuming.”

The team also shared their personalised approach to co-ordinating home care packages and how this has helped to address challenges with capacity.

“We have a member of our team who is dedicated to the domiciliary care side of the service,” explains Julie. “She speaks to the home care providers, rather than working by emails, and has built up a really good relationship. This means they now call us to inform us about their capacity levels and where we have a challenging discharge, we have the relationship with care providers so we can work together and to a solution, even when there are pressures on capacity.”

Luke Edwards, Director of Sector Development for NHS Improvement, commented on the visit: “It was really helpful to speak to Richard, Julie and team to understand the work that they do, and get their sense of the challenges across the wider pathway both locally and from a national perspective.”
Dr Richard Newland, chief executive of CHS Healthcare said: “We are delighted that the quality and value of our hospital discharge services are very widely recognised by Lord Carter and NHS Improvement.

“The visits to Surrey and Burton were a great opportunity to demonstrate all we do in detail; to show all work needed to achieve a timely complex discharge, the quality of our reporting and how we consistently meet our key performance indicators.

“We value our partnership with Burton Hospitals and were very pleased that NHS Improvement were able to come and see one of our schemes at ‘ground level’. Thank you to everyone involved.”

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