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April 7, 2020

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

By Uko Umotong, National Discharge and Community Services Manager

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.

As originally seen on LinkedIn

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