News

Hospital Discharge

Beyond summer pressures: Maximising patient flow through dedicated care coordination

Uko Umotong

 

Although we are painfully familiar with ‘winter pressures’ there has been a glut of reports highlighting the pressure on the NHS this summer – summer pressures.

This weekend the Institute for Fiscal Studies said that the waiting list for elective surgery could balloon to 14 million procedures by this autumn. Currently,  there are 5m people waiting for surgery. The difference relates the millions of ‘missing patients’ who would have, in a normal year, joined the waiting list but due to the pandemic have not come forward or are not yet on the list.

Hospitals and ambulance trusts have been reporting OPEL alerts at level 3 and 4 as they struggle to cope with unplanned admissions.  It was predicted back in the early days of the pandemic many people who didn’t seek care at that time would start to present to health services through emergency pathways.  Primary care is also experiencing the impact with many struggling to cope adding further pressure on A&E. Some GP practices are reporting that they may need to close or reduce services due to concerns about their ability to provide safe care under such a volume of demand. Staff challenges are also impacting with Newcastle upon Tyne Hospitals Foundation Trust closing 10% of its beds due to staff absences.

Looking at this from a distance it all feels overwhelming and paints a particularly bleak picture for this winter. The challenge ahead – to provide care for covid, seasonal flu, as well as support the restart of electives is no small feat. The simple truth is that regularly hospitals are operating with no spare beds at all. At the centre of all of this is patient flow – making sure patients are moving into services when they need and out as soon as they can.

It was therefore a welcome intervention from NHS Providers last week who called on the government to maintain funding for discharge to ensure that it is made as easy as possible to move medically optimised patients into rehab beds in the community. The emergency funding for hospital discharge removed the artificial barriers which were slowing down discharge – as Chris Hopson notes before the pandemic it wasn’t unusual for 20-30% of beds to be occupied by patients who were ready to move on.

This funding is important, but it is not alone enough to solve the epic demand related challenge for the NHS this winter. And it’s vital to note that capacity in the community is not infinite.  Where that capacity is providing complex care, it is in very short supply indeed. Therefore managing this carefully is critical to maintain flow out of rehab beds and into long term care releasing those rehab beds back for new patients.

But what else can be done? Admission avoidance is driving some of the most innovative and integrated projects in health and care. While efficiencies are being recognised at the backdoor (and there are more to be had) there are also efficiencies at the front door which support flow. Care Coordination is about working alongside patients as soon as they present at A&E, staying in close contact with family and carers, making sure that what these patients need to head back home is sorted and implemented as speedily as possible.  In a best-case scenario this results in no bed being needed at all but otherwise it aims to avoid a community rehab bed being used when it is unnecessary. Therefore reducing cost and maintaining that bed for someone for whom it is essential.  Critical to this is providing the capacity and dedicated skills to work closely with families and patients helping them to make the decisions and choices which will allow them to move from hospital to home quickly and safely.

Getting through the next eight months will be a rough ride but there is no shortage of innovation and commitment to get care right by utilising resources carefully and implementing innovative structures. The initial phase of the pandemic was a huge learning curve and much has been made of the positive learnings to come out of that difficult time. As we look ahead past summer pressures it is possible with the right funding, partnerships, and systems in place there is every opportunity for us to come out of winter with a better understanding of patient flow and how the front and back door can work differently together.

Managing safe discharge and Covid-designated spaces this winter

Uko Umotong, Hospital Discharge & Community Services Manager

Government guidelines request that NHS and local authorities ensure a 14-day isolation period for patients discharged from hospital into the community. As has been reported recently there are a limited number of beds designated for this purpose, which is why it is important that existing capacity is managed closely to deliver consistent and efficient patient flow. At the same time, we must provide a safe and reassuring experience for patients and their families.

We recently held our fourth session in our ongoing webinar series, “Managing safe discharge and Covid-designated spaces this winter”. Joining the webinar were guests from across NHS trusts, CCGs and local authorities. We were pleased to be joined by Natalie-Jane Macdonald, CEO, Sunrise Senior Living and Tina Snowdon, Area Manager CHS Healthcare to discuss the importance of efficient tracking and management of Covid-designated spaces under the new government guidelines this winter.

 

The challenge of designated settings

Speaking from her first-hand experience of seeing how Covid-designated settings were being handled and implemented, Tina noted that the process has been hindered where a “one size fits all” approach was taken, and that contextual insight is critical for each setting. 

As Covid-designated spaces are allocated, the primary blockers to efficient patient flow and correct implementation include the number of beds and space of the care provider, test results not coming back in a timely fashion, as well as simple lack of clarity regarding the next steps. People are often unsure of what is happening next and lack the necessary information required in determining whether a patient is ready to move on and where they need to be going.

Furthermore, as Natalie noted, designated settings are a good idea but for certain patients, such as someone with cognitive impairment, going to hospital in the first place is a hugely traumatic experience. To then move somewhere else – where they have likely never been – to be looked after and then to move again can cause significant deterioration in their level of functioning. “Our Sunrise or Gracewell home is our residents’ home. We have to be able to welcome them back from hospital whatever their status is,” she said. 

 

Tracking and oversight are critical for safe discharge

At the time of the webinar, the latest CQC data on Covid-designated settings and the South East showed that 1,500 beds had been provided by local authorities for use as designated beds, but only 141 of them were approved for use by the CQC. With a limited number of beds, we need to be able to know who is where at any given time and what their care needs are.

We are currently working well with the D2A model and designated discharge settings. “If we know where a patient is going before they leave hospital and we know that they are there for two weeks, then we can be planning while they’re in hospital, before they go to their designated discharge setting, and identify where they need to be going onwards from there. The flow has already been mapped before they leave hospital,” noted Tina. There have also been successes in using available hospital wards for the 2-week isolation period to avoid the use of an additional separate setting, though this is again subject to bed availability. 

Discharge planning should start at admission and this imperative doesn’t change because of Covid-19. “It is critical that we are using beds efficiently, ensuring tight tracking, making sure plans are in place and that everyone involved is aware of what is going on, including a patient’s family. When we pull these facets together, we can really have a slick and swift operation while ensuring as minimal impact to the patient as possible, as the patient is at the forefront of all our minds,” noted Tina.

 

Looking ahead

When asked about the current state of play, both Natalie and Tina agreed that it is essential to recognise that everyone is experiencing the same level of uncertainty, noting that each person and every organisation has a role to play in supporting care at this time. While it is critical to reduce and prevent infection, organisations must be focussed also on doing their utmost to maintain quality of life for patients and their families, for the limited time they may have together.

Looking ahead, the best way forward is to ensure clear and efficient communication amongst all partners, recognising that together we are able to cope with the challenges posed by the pandemic. Placing patients’ needs at the forefront of decision-making and efficiently implementing detailed planning and tight tracking of a patient’s journey through the system is the basis of effective patient flow.

As Tina concluded, “This year we have seen the ability for people to adapt and to pull together and work together and implement things that they never believed they could do”. This is the energy we need to continue with in the year ahead.

CHS Healthcare has been supporting CCGs with hospital discharge pathways nationally for 25 years  and are well-placed to support CCGs and local authorities to tackle their current and ongoing priorities. For more information, contact enquiries@chshealthcare.co.uk to discuss your needs.

You can access a recording of the webinar here: https://chshealthcare.co.uk/events/webinar-managing-safe-discharge-and-covid-designated-spaces-this-winter/   

Care homes trust our hospital discharge process

By Uko Umotong

An in-depth assessment of our work in East Yorkshire shows what care homes value:

  • trust
  • quality of information
  • communication and family support

East Riding of Yorkshire Council carried out the independent evaluation in January 2019 and asked care homes about their experience of hospital discharge co-ordination provided by CHS Healthcare.

The main themes are:

  • CHS Healthcare provide quality information and regular communication to care home which can sometimes be lacking in hospitals which are a busy and demanding environment
  • Care homes highlighted the importance of trust, when hospitals and care homes have different priorities in the discharge process this can sometimes create challenges

Quality information and consistent communication supports efficient discharge:

“The CHS Healthcare standard of calls is much better than the hospitals and the social workers.  Sometimes the care home can get three separate phone calls all about the same person; the calls are much better managed where CHS Healthcare is involved.”

Care home liaison means we can reduce pressure on wards and care homes:

“The wards are so busy that hospital staff don’t have time to speak when the care home manager goes to assess; sometimes it is difficult to know who to speak to on the ward.’’

We provide accurate referrals:

“The ward can be more generic in how they describe the person; the description from CHS Healthcare is much more accurate.”

We reduce anxiety for families and patients:

“CHS Healthcare will ring the care home and agree when it is appropriate to attend and then contact the family; the family seem more at ease, and better informed; whereas before, family would visit unprepared and not knowing what to ask / look at; families coming through CHS Healthcare appear less stressed and more comfortable.” 

“Usually CHS Healthcare meet the family and takes them to the care home which works very well. Families can be apprehensive but CHS Healthcare acts like an advocate to the family. Visits are always smoother if CHS Healthcare is there.” 

Super stranded patients

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

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

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

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

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

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

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.

Looking for care?Go to Carehome Selection
Skip to content