Maintaining visibility of older people discharged into the community, supports care now, and in the future

By Uko Umotong

The health and care sectors are responding to the coronavirus pandemic at unprecedented speed. Reflecting long held ambitions, they are developing new ways of working, such as digital primary and secondary care, being integrated almost overnight. At the back door, an accelerated pathway for discharge from hospital for medically optimised older people is well underway. Making sure these older people are able to leave hospital and receive care in the community is critical at this point – both for their own heath and to create capacity for those with coronavirus.

However, as with all changes within the health system, it’s critical to consider broader impacts.

What happens once these older people are placed in community? How are their ongoing care needs being met? What are their funding arrangements?  Who referred them? When are they due to have their care reviewed?

Failing to track older people discharged into the community under Covid-19 funding, puts us in danger of losing visibility of some of the most vulnerable people in our community. This could create problems for them that may not be realised for some months.

An immediate issue is how do we assure ourselves that they are not at risk of readmission? And for the future post-pandemic world, do we have the right information in place to quickly assess care and funding needs and reduce disruption and additional stress for older people and their families.

We provide patient management systems, Broadcare and Caretrack, to over 75% of CCGs.  These systems are used to record critical information on older people placed in the community. We also developed and run the NHS England national database for Independent Reviews for CHC funding.  We have now developed these databases to accurately track and monitor all patients receiving interim funding due to the Covid-19 crisis.

This means that we can remind CCGs when older people are due health and care assessments, we can record the outcome of those assessments and when Covid-19 funding is no longer available, it will be easier to understand what funding is available for care.

We track:

  • Demographic patient data (including NHS Number, registered GP etc)
  • Covid-19 test outcome data
  • Referral data – where the referral has come from (acute hospital, including ward)
  • Date of funding agreed
  • Discharge arrangements
  • Costs of care
  • Breakdown of actual care delivered
  • Contracts agreed with care providers – when sent out and when returned
  • Payment reporting on actual payments made to care providers
  • Alert/reminder functionality to ensure patient is reviewed at a minimum of 12 weeks
  • Ongoing assessment timeframe once crisis is over
  • All patient documents to support funding

There are a lot of unknowns at this time and the focus is rightly on helping those who are medically fit to be discharged from hospital and into care. Good crisis management however requires a focus on planning for exit from the acute phase. After the Covid-19 crisis, we will need to ensure that we understand the wider picture of care for older people and that information exists to support longer term decisions.

NHS England asks Trusts to move 15,000 super stranded patients out of hospital and into community by end of week

By Uko Umotong

NHS England have asked Trusts to move 15,000 super stranded patients out of hospital and into the community by the end of this week to create urgent capacity for the coronavirus. We can help. We work with over 50 trusts across all D2A pathways, CHC and trusted assessor. We have a totally remote workforce who can start immediately. We can also support through the coming weeks with visibility on patients in the community to help make sure they don’t return as an unplanned admissions. We have unparalleled knowledge and insight of local care provision, we can support ongoing capacity by providing dedicated hospital discharge support throughout this challenging time

We need to make sure older people get the right care in the community to reduce demand in the long term

By Gabrielle Silver

Sir Simon Stevens has said he wants people who have been in hospital for over 21 days to be discharged urgently to release capacity for coronavirus. This is the right thing to do, but it’s equally important older people get the right care in the right place to avoid unplanned readmissions. Bouncing back into hospital will expose them to risk of infection and put further pressure on hospitals facing unprecedented demand. Our deep local knowledge and insight means we can make sure older people get the right care in the right place. #coronavirus #rightcareintherightplace

Creating capacity now with our rapid discharge services

By Uko Umotong

We are patient discharge experts and can help support older people put of hospital and into the right care for them now.

With more than 20 years’ experience supporting the NHS, CHS Healthcare can help create capacity for coronavirus patients in NHS Trusts during this pandemic. We have deep knowledge and insight of local care and are able to support discharge at pace. Hospital is not the right place for a recovered older person, and it is especially urgent they are moved out of hospital at this challenging time – both for their own health as well as releasing capacity.

We’re keen to help the NHS at this time – please get in touch.

Simon Stevens calls for NHS to focus on discharging patients in hospital over 21 days

By Gabrielle Silver

Today NHS CEO Sir Simon Stevens called for the NHS to focus on the discharge of patients who have been in hospital for over 21 days, and many of whom will be older and medically fit to leave. We welcome his focus on this issue. It is imperative at this time, as well as creating capacity at pace, insight and knowledge around local care provision is used to place older people in the very best location for their needs. Pace and quality are not at odds.

We know from experience that older people placed in the wrong care will bounce back into hospital. This would be hugely harmful exposing them to services stretched beyond capacity and infection risk. Social care has capacity and it is important that this is utilised effectively. Working with partners who have this deep knowledge and insight of local care provision will reduce the risk of readmission of older people keeping them safe and reducing unnecessary demand at this critical time.

The physical and mental toll of the stranded elderly

As hospitals face what Simon Stevens recently described as the biggest threat to the NHS since it was created, we’re reflecting on the importance of helping those older people who are ready to leave hospital into care at home or in the community as soon as they are medically fit to do so. We’ve spoken with a consultant geriatrician about the risks for older people when they remain in hospital once well.

 “What shocks me is that every winter it seems to come as a surprise to many people that we are in this position – but the same issues arise every year”

“During the winter, helping patients to arrange safe discharges from hospital becomes much more difficult. I’ve been a geriatrician for 20 years and it’s worse than it ever was.  

It upsets me to see patients inappropriately stuck in acute hospital beds. As they wait for a package of care they are at increased risk of infection, all the while deconditioning, losing confidence and becoming institutionalised. And these are frail and elderly people who have a life expectancy of perhaps two or three years, but six months of that is being taken up by delays in navigating a broken system. Sadly, it is not uncommon for them not to make it out of hospital.

Social services have no funding or resource, and don’t always know where the care home spaces are. Illogically, you end up resenting them, but it’s not their fault. The red tape when securing someone a place in care is horrendous: there are multiple forms and questionnaires to complete, which causes a built-in delay. This means people have to go into ‘step-down’ beds, which is just a creative workaround to deal with unwieldy regulations and the split in health and social care budgets. But the patient is still not in the right place for their needs. As well as the impact on the patients stuck in bed, it also means we can’t bring in other patients who are waiting in casualty or inappropriate wards.

One gentleman was on the ward for 250 days, at least 150 of those days were because of discharge difficulties, such as the inability to access the right care and the family having inappropriate expectations. We had multiple meetings with his family, which took up hours of clinical time from a multitude of healthcare professionals, to demonstrate that staying in hospital wasn’t the best thing for him. As expected, he ended up getting an infection whilst waiting for appropriate discharge arrangements.

For the families who have been thrown into these situations, it is difficult and stressful to navigate the health and care system. They are often under the misconception that the hospital is the safest place for their family members to be waiting. Doctors and nurses don’t have the time or resource to support families with this, in addition to fulfilling ever-increasing clinical demand, so we have developed dedicated discharge teams to help find the most appropriate place for their loved ones.

But what shocks me is that every winter it seems to come as a surprise to many people that we are in this position – but the same issues arise every year. Right now, the number of patients ‘in delay’ make up about two or three wards-worth of patients.

  • On average, over the whole of winter (December 2019 – February 2020) 16,112 beds a day were taken up by super-stranded patients
  • An average of 1,981 ambulance handovers a day were delayed by more than 30 minutes (an average of 14% of daily ambulance arrivals)
  • In January 2020, an average of 5,182 patients a day (acute and non-acute) experienced delayed transfer of care, meaning that they are medically fit to leave hospital but is still occupying a bed, resulting in a total of 160,637 ‘delayed days’

Sources: NHS Statistics Winter Situation Reports 2019/20, NHS Statistics Delayed Transfers of Care 2019/20

We need to make sure older people get the right care in the community to reduce demand in the long term

By Gabrielle Silver

Over the last week there have been significant developments around the management of the coronavirus with a lot of advice directed towards older people who may be at risk.

On Tuesday (17 March) in a letter sent to the NHS, Sir Simon Stevens asked for a range of measures to be implemented to help the NHS cope though the coronavirus pandemic. One of these was that the NHS cancel routine elective operations and another that they urgently discharge any patients medically fit to leave.  At a session with the Health Select Committee he said:

“Community health providers must take immediate full responsibility for urgent discharge of all eligible patients identified by acute providers on a discharge list. For those needing social care, emergency legislation before Parliament this week will ensure that eligibility assessments do not delay discharge.

“This could potentially free up to 15,000 acute beds currently occupied by patients awaiting discharge or with lengths of stay over 21 days.”

This is an important moment. We know that older people who are medically fit to leave and remain in hospital suffer physical and mental decline.  As an NHS geriatrician we talked to recently said in a blog published on our website.

As they wait for a package of care they are at increased risk of infection, all the while deconditioning, losing confidence and becoming institutionalised. And these are frail and elderly people who have a life expectancy of perhaps two or three years, but six months of that is being taken up by delays in navigating a broken system. Sadly, it is not uncommon for them not to make it out of hospital.

This comment is reflecting on the situation during a normal winter. Remaining in hospital in the current pandemic scenario they also stand to be exposed to the virus which would not only have a huge impact on their health, and possibly be fatal,  but also add to the demand for care through the NHS at a time when this demand is at unprecedented levels.

Avoiding readmission into hospital is also of paramount importance and this can only be achieved through a dedicated focus on ensuring that   patients are discharged with the right care package to meet their needs either at home or in the community. Where a provider is caring for someone with needs beyond their facilities and experience, they are more likely to become ill and return to A&E.

Realising capacity is an urgent matter but pace and quality do not need to be at odds. There is capacity in social care – it needs to be carefully managed.  Deep local insight and knowledge is crucial to understanding where this is and what people it will suit best.

This is a particularly challenging time for families as they navigate care for loved ones in a highly anxious environment.  Our teams are working in trusts across the country right now and support over 20,000 people to find care each year. We are dedicated to helping and supporting families to make choices about care and we have unrivalled knowledge of the local care sector.  We have also adapted our ways of working with our teams support remotely supporting patient safety and infection control measures.

We know this is a tough time for the NHS and our teams are supporting across the country.  We’re proud of the work they are doing and we stand ready to help wherever we are needed.

NHS ramps up preparation for threat of a pandemic, government to help medically fit leave hospital

By Gabrielle Silver

As the NHS ramps up its preparation for the threat of a pandemic, the government has highlighted the importance of helping people who are medically fit to leave hospital to help create capacity for increased admissions. This is a challenging time for the health system with little capacity to utilise should pressure increase. As Matt Hancock stated today, responding to this threat will demand a nationwide effort with partners across the health system pulling together to ensure the NHS can continue to provide care when needed.

We are the experts in patient discharge and support NHS partners across the country. We have real time understanding of local care capacity. We’ve been working with NHS trusts for more than 20 years helping discharge patients back home with support, or into care home facilities. We are currently located in more than 50 NHS Trusts and last year discharged over 20,000 patients. We work across all funding streams with a KPI from referral to discharge is 5 days, often less, and we can mobilise within 2 weeks.

Most importantly our service can be provided remotely so will not be impacted by infection control measures.

We’re committed to playing our part to make sure everyone can get the right care in the right place regardless of their underlying condition.

CHS support for Local Authorities

We’re a week away from the first budget from our new government. Social care is high on the agenda and is expected to be a key aspect of the new Chancellor’s speech. Back in December 2019 the government committed that Councils would receive an additional £1bn for adult and children’s social care in every year of the parliament, along with a pledge to consult on a 2 per cent precept that would enable councils to access a further £500m for adult social care for 2020-2021.

Reports this week have confirmed that many councils are aiming to raise their council tax by up to the maximum 3.99 per cent in a bid to stave up struggling social care services. There is no doubt that demand for social care services will remain high. Even with additional funding, increased demand and increasing costs mean the sector is under extreme pressure.

Continuing healthcare (CHC) makes up a large proportion of the funding for care and the government 2018/19 mandate to NHS England stated that ‘the identified large efficiency opportunities requiring concerted action across the system… are a critical part of balancing its budget’1.

A total of £855 million from the budget for NHS continuing healthcare has been earmarked as an efficiency saving. To achieve this, the Treasury has called for four improvements:

  • clarity around the national framework (better data and benchmarking)
  • better commissioning of care
  • local CCG efficiencies
  • improved processes through supporting staff with training and development2

With these budget challenges coming from two sides, it’s never been more important to have complete understanding of who needs to receive care and from which budget. Earlier this month, Which? magazine published analysis of NHS data which showed significant variation in continuing healthcare – for example people in Salford were nearly 18 times more likely than those in Luton to get funding (211 vs 12 people per 50,000 in receipt). Clearly demographic differences could explain this variation, but the challenge is how the framework is applied locally.

Independent dedicated resources that assess applications for CHC, manage any backlog and keep pace with reviews are key to ensure that those people meeting the requirements for CHC support receive it. At CHS Healthcare we have over 20 years’ experience working with the NHS and Social Care.  We have a whole system approach and give impartial advice by applying the national framework fairly bearing in mind lawful limitations and this means we can support consistent application reducing variation across the system.

  1. DSHC, The Government’s revised mandate to NHS England for 2018-19 (May 2019), paragraph 2.8. For 2019/20, the Government published its mandate as part mandate as part of the NHS Accountability Framework 2019-20 (May 2019)

Why the NHS is failing those with learning disabilities

Arthur Calder Head of clinical services at CHS Healthcare

First published in the Health Service Journal, 6 February 2020

As a mental health nurse by background, I can categorically state that reviews of the deaths of patients with learning difficulties will continue to be side-lined if inadvertently left by clinical commissioning groups to my former peers and colleagues at mental health trusts (Exclusive: Death review backlog still growing despite NHSE commitment, 8 January 2020).

Increasing backlog of cases

The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016. The system, coordinated by the University of Bristol, is meant to ensure reviews are carried out within six months of a relevant death being flagged to the local CCG.

However, as the HSJ revealed last month, the backlog of cases not reviewed is growing. This is despite an extra £5m improvement fund pledged by the government more than six months ago, after its annual report first revealed the backlog problem. It has been obvious for some time that there was a backlog of LeDeR reviews building up. The HSJ data illustrated the true scale of the gridlock.

In many cases, mental health trusts have been commissioned by CCGs to undertake learning difficulty patient death reviews, with learning difficulty nurses carrying them out on the ground (a responsibility that sits on top of their remarkably pressurised day job).

The problem is that learning difficulty nurses often don’t receive the necessary on-site clinical and managerial supervision in order to translate the virtual learning provided by Bristol University into the practical, analytical skillset needed to undertake the bulk of the review.

Make no mistake: learning difficulty nurses’ specialist clinical and professional skills are second to none. But they should not be expected to take on full responsibility for these reviews that require a range of medico-legal skills, experience and understanding of formally assessing the circumstances around a patient’s death in addition to their existing commitments.

The CCGs delegation of this responsibility to mental health trusts that don’t have the necessary governance resource and retrospective review experience is the real area for concern behind this mounting backlog of unreviewed deaths.

Unless this is addressed, no amount of new money thrown at this is going to solve the problem. Let’s not forget the fundamentals here – our primary obligation to give grieving families context, understanding and a sense of closure.

 A progressive project

While the LeDeR programme is a vital project allowing the NHS to listen and learn from events, to revisit such memories years post the event isn’t in anyone’s best interests. Early intervention is critical in such cases, and actually the clinician can also make a truly positive difference to the feelings and emotions running raw at such times. Families need to know that we care, that we listen, and that we act.

Ironically, the LeDeR review project is at risk of demonstrating the same system breaches that it was commissioned to investigate. Indeed, it is being hamstrung by the most common problems highlighted by local reviewers, such as significant delays in delivering the reviews, staff training, care coordination and poor communication.

We remain public servants. Essentially, we already have a skilled, untapped workforce sitting within a parallel service that could support the LeDeR framework nationally (including those who have access to vital clinical histories).

I have seen these issues stymie the best intentions of policy and public resources time and again as part of my work with CHS Healthcare teams helping to deliver NHS Continuing Healthcare nationally and LeDeR in a small number of CCGs.

We can do a lot better than this. These reviews were created to understand how care could be improved for people with learning difficulties. We must do better for these people and their families as well as those who are currently receiving care.

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