Hospital Discharge

Utilising the stranded patient concept to improve patient flow

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

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

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.”

It’s the season of poor hospital discharge capacity – and it starts in November

By Susan Adams, CHS Healthcare manager, south England

The myriad of “winter pressures” on the NHS is evident each year, but the exact interplay of the different causes is challenging to understand. This winter, we have already had familiar scenarios of ambulances waiting outside accident and emergency departments, unable to handover their patients to hard-pressed units. A&E performance is regularly presented as a ‘litmus’ test for NHS resilience. Yet there is not a straightforward equation of winter producing more sickness and therefore more patients arriving at the front end of hospitals. As the Kings Fund states, emergency attendances are typically lower in December and January than during the summer. Whether winter admissions are sicker and more frail during winter is certainly the case for a significant number, but hard to quantify overall.

What we do see, in a clear and measurable way, is the impact of the Christmas holiday period upon discharge capacity as a whole. CHS Healthcare provides discharge co-ordination services in 35 NHS acute hospitals across England and it is observable that in some cases, the impact of Christmas commences in November. Last year in the south-west, for example, where we co-ordinate Fast Track care for patients whose wish is to return to their own homes for their final weeks of life, one major domiciliary care provider told us early in November that they would not be able to provide any new packages of care for 12 weeks. This pattern has been repeated this year: a continuing healthcare lead in the south-east stated that if home care was not in place very early in December, there would be no likelihood of it being provided before the New Year. Why this sudden fall in home care capacity? Domiciliary care is provided by low paid workers who are often on zero hours contracts. Many choose to work fewer hours over Christmas, often because they cannot afford the high costs of childcare while their children are off school.

An operations planner in the Midlands suggests that this fall in whole system discharge capacity over the Christmas period means that at the start of January, when social care operations are returning to normal capacity levels, there is such a backlog of patients from the November and December delays that the whole system is unable to ‘catch up’ for many more weeks.
What can we do? In our service for Fast Track patients in the south-west, we had to find compromises: patients who wanted to be in their own homes with support for their final weeks were very sadly unable to do so, but to remain in hospital was a particularly poor option, so we sought good nursing home places. This too was difficult as capacity here was also limited. We provide a consistent focus on the discharge process, which is ever more critical when capacity tightens. Regularly, we make 30 or 40 phone calls per discharge, we have advisers visiting care homes to ensure managers come to hospital to assess, our evaluation shows how we routinely ‘go the extra mile’ to make a discharge happen during this tricky Christmas period (whose effect can be seen potentially from November deep into January).

Of course, this is only one element of winter pressures and there are many more. This is a common theme of discussion among discharge teams, yet it is rarely aired more widely and illustrates how a traditional holiday period can drive pressures, both with and without any accompanying rise in cold related sickness.”

The New Discharge to Assess Guidance Signals New Ambition for Outcomes for the Elderly

By Susan Adams, CHS Healthcare Manager, south of England

We are all extremely familiar with delayed discharges (DTOC) as a vital sign of how a hospital and the surrounding health system is performing. In addition to DTOC, another measure has been introduced whose apparent simplicity belies the ambition it holds for care of the elderly.

NHS England states Trusts must reduce the number of continuing healthcare screenings and full assessments taking place in an acute location. There is a wealth of evidence to show how rapidly older people’s capacity declines in hospital. Ten days of bed rest leads to a 14 per cent reduction in leg and hip strength and a 12 per cent reduction in aerobic capacity. Muscle strength in hospital can decline by as much as five per cent per day. This inevitably impacts on their ability to perform key tasks: one study found that people over the age of 70 in hospital declined by 12 per cent in the function bathing, eating, moving around and going to the toilet.

Therefore, by assessing an older person in an acute setting, we are measuring their capacity at the time when it is likely to be at its lowest level. There is also the ‘double whammy’ that by keeping them in hospital awaiting an assessment, we are causing their capacity to diminish further. In so doing, the risk is they will go from hospital to long term care, rather than having a prospect of recovering sufficiently to return to their own home.

A hospital based assessment is only appropriate for the small minority of patients with very complex health needs that are unlikely to change very much over time. But the large majority of those currently having hospital based assessments are in the ‘frail elderly’ category, which is recognised as being a continuum, with potential for both improvement and deterioration.

We have seen this in practice in the service we provide in Gloucestershire, where we have worked since 2014, developing what we do from simple hospital discharge support and co-ordination to a full discharge to assess (D2A) pathway. Working with up to 50 patients each month, we have many examples of individuals who are able to return to their own home after a period of reablement in their D2A placement. Without the D2A pathway, many patients would have gone straight from hospital to long term care.

Examples include a 96-year-old man: after a hospital admission, he required a Sara Stedy to transfer and was very fearful of falling. Two weeks of physiotherapy followed by a rehabilitation placement enabled him to return to his level of mobility before hospital admission and return to his own home. A 94-year-old woman who was admitted to hospital with sepsis moving into a nursing D2A bed with a high level of confusion and was dependent upon a hoist for all transfers. Twice weekly physiotherapy sessions have enabled her to move to step transfers with frame and she is now in a community rehabilitation bed with the plan for a return home.

For some people, a long term care placement is the best and safest option. But it is recognised that too many elderly people go into long term care after an episode in hospital when they had the potential, with time and support, to return to their own home. Of course, moving older people out of hospital for assessment and reablement will significantly improve DTOC rates. But a systems based view must not diminish the principle behind this measure: by assessing out of hospital, we are giving elderly, frail individuals their best possible chance of returning to their own home and that is a goal we must strive to achieve.

Directly employed social workers in new flexible discharge to assess model

We are employing social workers in a new, flexible discharge to assess model in Gloucestershire Royal Hospital.

Providing services in Gloucester since April 2014, our well-regarded team have already established a flexible model for nurse assessments. We employ experienced nurses who carry out assessments during evenings and weekends.

By working flexibly, the nurses ensure no time is lost and meet families at times they find most convenient. For example, between December 2014 and May 2015, our nurses completed 221 assessments for patients moving from hospital into a care home. They took an average of just 1.8 days from referral to assessment being completed (this can take up to ten days in some areas).

From January 2016, we will be extending the same flexible model to the social work assessment. We will co-ordinate the whole of the discharge to assess process, employing and managing the social workers and nurses to ensure assessments are co-ordinated without delays.

The team will be spot purchasing beds across Gloucestershire and commissioning physiotherapy and occupational therapy.

Discharge to assess is based on the principle that once a patient is fit for discharge from hospital, they move into a community based bed in order for further assessments to take place. The model is effective in reducing lengthy delays in acute beds and ensuring the patient receives the assessments and support they need in the community, before a decision about their long term care is made.

Susan Adams, CHS Healthcare Manager for the south of England, said: “We are really delighted to launch this model which enables us to manage all the different parts of the ‘jigsaw’ of the discharge to assess process.”

“Having this full oversight, by employing social workers ourselves, gives us control of the whole workflow. We can avoid the delays that have traditionally arisen when one part of the health and social care sector is waiting for another part of the sector to carry out an assessment. We have proven the flexible working model works for the nurse assessments. By working during evenings and weekends, valuable time is not lost and equally, it works for families – many people have daytime work commitments and want to see the nurse during evenings or weekends.”


The first net fall in care home beds revealed in two major studies: the impact we see on the frontline

By Rachael Hardbattle, CHS Manager, Midlands and north of England

For the first time, more care home beds are closing than new facilities opening. Two independent reports have cast some statistical light upon overall capacity in the care home sector. They show total bed numbers have fallen by 3,000 in a single year and for every home that opens, two other homes close.

Perhaps the most surprising thing is how little attention both these reports have received across the media. Hospital bed numbers, pressures and occupancy fill the national press on a weekly basis. Yet neither of these two reports on community based beds made more than a ripple in the news cycle.

LaingBuisson’s Care of Older People market report provided an analysis of overall capacity, compiled from care home registrations and closures (October 2014 to March 2015). Their report noted a 3,000 fall in capacity; the first time that there has been a net decrease.

Social care property advisers Healthcare Property Consultants also covered the same issue from a different angle, reporting that for every two care homes that close, only one new home is opened. Their report noted that smaller, independent care homes were more likely to face closure and the new care homes opening are typically larger and run by national chain providers.

The LaingBuisson report notes that in 2014 there were 433,000 older or physically disabled people living in residential care settings, with 487,000 beds available. That means care home occupancy rates of 90 per cent: a five year high that is comparable to occupancy levels in many under-pressure hospitals.

It is important to note that there is huge regional variation, depending on the funding streams for the care home sector in each area. Where most residents are self-funders, care homes are faring fairly well. Where most are state funded, the squeeze is most acutely felt.

At CHS Healthcare, we have a clear vantage point to observe these variations: we run hospital discharge schemes throughout the country, including a large number of services from hospitals in the south-east and north-west of England. Inevitably, in the north-west, where more care homes are heavily dependent upon state funded residents, capacity pressures are very clear.

In Preston, for example, we have been a running hospital discharge support service since 2012, finding care home places for 80 to 90 hospital patients each month. We know the work flows required to enable patients to move into community based care and we have rigorous performance indicators to ensure all steps are taken without delay. However, increasingly, no matter how well we manage the process discharge, the challenge is this: for some patients, the community based beds our patients need are simply not there.

In Preston alone, eight care homes closed during the last 12 months. Additionally, when two homes re-registered, they both changed to residential beds only, with no nursing capacity. A further three homes are currently open but on staged admissions, due to issues raised in CQC inspections. This means they can only accept a smaller number of admissions each week (usually one to three). When there is an immediate suspension, the priority for nursing places within that area goes to people resident in that suspended home (their priority being higher than a person who is in hospital and waiting for a nursing bed).

What this all means is that the staff working in our experienced team in Preston can struggle to find care for patients who have nursing needs, particularly if those needs are complex.

Care homes tell us it is no longer viable for them to admit people with complex nursing needs because local authority funding has not increased and because they struggle to recruit qualified nurses.

Across the country, people with low (residential) needs, self-funders and the minority who are able to pay large top-up fees generally have a good choice of care homes. For those with complex nursing needs, there can be little or no choice: typically, it will take many phone calls, discussions and often involve a delay until a home is willing to accept these patients. Meanwhile, they wait in hospital, even though everyone recognises this is not the best place for them.

Patient and family choice in delayed hospital discharges: addressing the factor you can change

By Dr Richard Newland, CHS Healthcare chief executive

It is recognised that a myriad of medical, individual and organisational factors produce delays in hospital discharge. The problem is precisely recorded. Statistics released in the NHS Monthly Situation Report tell us, for example, that in July 2015, there were 4,881 patients delayed in an acute care bed. This amounts to 147,005 delayed bed days, representing the total figure for acute care being provided beyond the stage when it is clinically needed, in a single month.

The report drills down further into reasons for these delays. NHS delays are the most common cause of delays, where patients are waiting for further non-acute NHS care such as rehabilitation services or an intermediate bed. This accounts for 17 per cent of the total delays. The second largest factor is waiting for an assessment, producing 11 per cent of delays. Patient or family choice produces the third highest numbers of discharge delays, at 9 per cent of the total. This is not an insignificant proportion – choice was responsible for 11,911 delayed bed days across England in July 2015 alone.

What is the scenario behind a delayed discharge due to patient or family choice? This is something we repeatedly see and discuss with our NHS partners. When patients need to choose a care home in order to leave hospital, ward staff often do not have time to do more than provide a directory listing hundreds of care homes. Many patients and families, understandably, find this overwhelming. Choosing a care home for a parent or relative is commonly a difficult, emotional challenge and left without support and guidance, families will flounder and delay. Family choice can be particularly challenging if next of kin live far from the elderly relative, if there is a lack of transport to view homes and disputes between family members can occur, causing complex delays.

Self-funding patients are a growing proportion of home of choice patients; across the south-east, accounting for more than 70 per cent of patients who need to choose a care home in order to leave hospital. Without the support which comes with social services funding for long term care, self-funders are widely recognised as being at a high risk of delayed discharge.
Our work is founded on the recognition that when patients and families need to choose a care home, this should be a supported process. Left to do this alone, people frequently feel daunted and poorly equipped. Our advisers have the experience and local knowledge to help families focus on the care homes most appropriate for them, supporting them through visits and each step. In this way, they are making an informed, supported choice.

We regularly carry out evaluations with the families we have worked with and ask – how would you have managed to choose a care home without our service? The most common answer is: we would have got there in the end, but it would have far more challenging, stressful and would have taken a lot more time.

From a health and social care systems perspective, there is a simple message: some of the causes of delays to discharge are not easily addressed or changed. Organisational factors such as patients transferring to other parts of the NHS or assessments taking place are critical challenges to address, but may take time as they involve a complex health and social care system.

On the other hand, patient and family choice as a significant cause of delays is something that can be quickly and effectively addressed. Our dedicated, personalised support for families choosing a care home is proven to reduce delayed bed days by at least 50 per cent and equally, to enhance the experience for service users.

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